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COLLEGE  OF  OSTEOPATHIC   PHYSICIANS 
AND  SURGEONS  •  LOS  ANGELES,  CALIFORNIA 


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Radiograph  of  a  Healthy  Child's  Chest. 


\XHYSICAL   DIAGNOSIS 

OF 

DISEASES  OF  THE  CHEST 


BY 


RICHARD   C.  CABOT,  M.D. 

PHYSICIAN  TO  OUT-PATIENTS,  MASSACHUSETTS  GENEKAL  HOSPITAL.  ;  ASSISTANT  IN 
CLINICAL  MEDICINE,   HABVABD  MEDICAL  SCHOOL 


WITH   ONE   HUNDRED  AND 
FORTY-TWO    ILLUSTRATIONS 


NEW   YORK 

WILLIAM    WOOD    AND    COMPANY 

M DCCCCI 


Copyright,  1900, 
Bt  WILLIAM  WOOD  AND  COMPANY. 


TO 

FREDERICK   C.   SHATTUCK,  M.D. 

Jackson  Professor  of  Clinical  Medicine 
in  Harvard  University 

IS  EVIDENCE  OF   MY   APPRECIATION  OF 

THE    EXAMPLE    OF   SINCERITY,    COMMON    SENSE,    AND    ENTHUSIASM 

ESTABLISHED    BY    HIM    IN    THE    TEACHING    AND 

THE   PRACTICE  OF   MEDICINE 


7 

TO 


I 


PREFACE. 


This  book  is  intended  for  students  and,  so  far  as  I  am  aware, 
contains  nothing  original.  I  have  written  it  because  I  have  not 
been  able  to  find  any  small  work  upon  the  subject  which  does  not 
contain  glaring  errors.  The  correct  books  are  too  large ;  the  small 
books  are  out  of  date  and  repeat  such  well-worn  myths  as  that  the 
aortic  second  sound  is  normally  louder  than  the  pulmonic  second, 
that  aortic  regurgitant  murmurs  are  usually  best  heard  in  the  sec- 
ond right  interspace,  that  a  hypertrophied  left  auricle  can  produce 
dulness  and  pulsation  near  the  left  sternal  border,  that  systolic  re- 
traction at  the  cardiac  apex  means  adherent  pericardium,  that  epi- 
gastric pulsation  denotes  hypertrophy  of  the  right  ventricle,  etc. 
Further,  none  of  the  smaller  text-books  contains  any  adequate  ac- 
count of  muscle  sounds,  of  pulmonary  atelectasis,  or  of  adherent 
pericardium.  To  record  the  well-known  but  often  forgotten  truth 
on  such  matters  as  these  has  seemed  to  me  of  importance  in  small 
books  as  well  as  in  encyclopaedic  treatises. 

The  diagrams  illustrating  respiratory  types  are  modifications  of 
those  used  by  AVylie  and  Sahli. 

I  am  indebted  to  Mr.  Eliot  Alden,  of  the  Harvard  Medical 
School,  for  his  kind  assistance  in  the  preparation  of  the  illustra- 
tions and  to  Drs.  E.  C.  Bradford  and  R.  W.  Lovett  for  permission 
to  use  three  cuts  from  their  well-known  work  on  orthopedic  sur- 
gery. 

I  am  also  indebted  to  the  editor  of  the  Archives  of  the  Rontgen 
Ray  for  permission  to  use  two  radiographs  from  that  journal. 


5\'5'oe5 


ERRATA. 

1.  Page  35,  line  7,   for  "expiration"   read  "inspiration". 

2.  Page  81,  last  line,  first  word,  for  "of"  read  "or". 

3.  Page  120,  in  the  legend  underneath  Fig.   78,  for  "pulmonic" 

read  "aortic". 

4.  Page  125,  last  line  but  one,  for  "found"   read  "sound". 

5.  Page  261,  line  11,  for  "aphonic"  read  "aphonia". 

6.  Page  299,  third  paragraph,  for  "three"  read  "two". 


TABLE  OF  CONTENTS. 


PAGK 

Introduction,      ............      1 

I.  Methods  of  Examining  the  Thoracic  Organs, 1 

II.  Regional  Anatomy  of  the  Chest, 2 


PART   I. 

TECHNIQUE   AND   GENERAL   DIAGNOSIS. 

CHAPTER   I. 
INSPECTION. 


I.  Size,  .... 

II.  Shape,        .... 

(a)  The  Rachitic  Chest, 
(6)  The  Paralytic  Chest, 
(c)  The  Barrel  Chest,      . 

III.  Deformities, 

(a)  Curvature  of  the  Spine, 

(b)  Flattening  of  One  Side  of  the  Chest, 

(c)  Prominence  of  One  Side  of  the  Chest, 

(d)  Local  Prominences,  . 

IV.  Respiratory  Movements, 

(a)  Normal  Respiration, 

(6)  Anomalies  of  Expansion, 

1.  Diminished  Expansion, 

2.  Increased  Expansion, 
(c)  Dyspnoea, 

V.  The  Respiratory  Rhythm, 
(a)  Asthmatic  Breathing, 
(6)  Cheyne-Stokes  Breathing, 

(c)  Restrained  Breathing, 

(d)  Shallow  and  IiTegular  Breathing, 

(e)  Stridulous  Breathing, 


5 

6 

7 
8 
9 
12 
12 
14 
14 
15 
16 
16 
16 
17 
18 
18 
21 
21 
21 
22 
22 
23 


Vlii  TABLE  OF  CONTENTS. 

PAGE 

VI.  Diaphragmatic  Movejients  (Litteirs  Phenomenon),      .        .        .23 

VII.  The  Cardiac  Movements, 26 

1.  Xormal  Cardiac  Impulse, 26 

2.  Displacement  of  the  Cardiac  Impulse, 29 

3.  Apex  Retraction,       ....                  ....  31 

4.  Epigastric  Pulsation 32 

5.  Uncovering  of  the  Heart, 32 

VIII.  Aneciusm  and  Othek    Causes  of  Abnormal  Pulsations  of  the 

Chest  Wall, 3.5 

IX.  The  Peripheral  Vessel*.        ........  34 

(a)  Venous  Phenomena, 36 

(b)  Arterial  Phenomena, .         .36 

(c)  Capillary  Phenomena 38 

X.  The  Skin  and  Mucous  Membranes, 39 

1.  Cyanosis, 39 

2.  CEdema 40 

3.  Pallor, 40 

4.  Jaundice, 40 

5.  Scars  and  Eruptions 41 

XI.  Enlarged  Glands, 41 


CHAPTER   II. 
PALPATION    AND   THE   STUDY  OF   THE    PULSE. 

I.  Palpation, 42 

1.  The  Cardiac  Impulse. 42 

2.  Thrills, 43 

3.  Tactile  Fremitus, 44 

4.  Friction.  Pleural  or  Pericardial, 46 

5.  Palpable  Rales 47 

6.  Tender  Points, 48 

7.  Abnormal  Pulsations 48 

8.  Tumors, 48 

9.  Temperature  and  Quality  of  the  Skin, 49 

II.  The  Pulse, 49 

1.  The  Rate 51 

2.  Rhythm, 51 

3.  Compressibility, 62 

4.  Size  and  Shape  of  Pulse  Wave, 52 

6.  Tension, 53 

6.  Size  and  Po.sition  of  Artery. 55 

7.  Condition  of  Artery  Walls, 65 


TABLE  OF  CONTENTS.  IX 
CHAPTER    III. 
PERCUSSION. 

PAGE 

I.  Technique, 58 

(  Mediate  Percussion, 58 

'^'  "/  Immediate  Pei'ciissioii, 58 

(&)  Auscultatory  Percussion, G5 

(c)  Palpatory  Percussion, 67 

II.  Percussion-Resonance  of  the  Normal  Chest,         .         .         .         .67 

(a)  Vesicular  Resonance, .68 

(6)  Dulness  and  Flatness, 68 

(c)  Tympanitic  Resonance, 70 

(d)  Cracked-pot  Resonance, 74 

(e)  Amphoric  Resonance 75 

(/)  The  Lung  Reflex, 76 

III.  Sense  of  Resistance, 76 

CHAPTER  IV. 

AUSCULTATION. 

1.  Mediate  and  Immediate  Auscultation,      .                  .         .         ,         .  77 

2.  Selection  of  a  Stethoscope 78 

3.  The  Use  of  the  Stethoscope, 83 

A.  Selective  Attention  and  What  to  Disregard,          ....  84 

B.  Muscle  Sounds, 86 

C.  Other  Soui'ces  of  Error, 88 

4.  Auscultation  of  the  Lungs,        ........  91 

I.  Respiratory  Types, 92 

(a)  Vesicular  Breathing, 93 

(6)  Tubular  Breathing, 95 

(c)  Broncho-vesicular  Breathing, 96 

(d)  Emphysematous  Breathing,  .......  97 

(e)  Asthmatic  Breathing 97 

(/)  Cog-wheel  Breathing, 98 

{g)  Amphoric  Breathing, 98 

(h)  Metamorphosing  Breathing,  .......  98 

II.  Differences  between  the  Right  and  the  Left  Chest,         .        .        .99 

III.  Pathological  Modifications  of  Vesicular  Breathing,        .        .        .99 

(a)  Exaggerated  Vesicular  Breathing,         .         .        .        .         .  99 

(6)  Diminished  Vesicular  Breathing. 100 

IV.  Bronchial  Breathing  in  Disease, 102 


t  TABLE  OF  CONTENTS 

FA6K 

V.  Amphoric  Breathing, 103 

VI.  Rales, 103 

(a)  Moist, 103 

(b)  Dry, 104 

(c)  Musical, 106 

VII.  Cough.     Effects  on  Respiratory  Sounds, 107 

VIII.  Pleural  Friction, 107 

IX.  Auscultation  of  the  Voice  Soimd, 109 

(a)  The  Whispered  Voice, 109 

(b)  The  Spoken  Voice, 110 

(c)  Egophony, Ill 

X.  Phenomena  Peculiar  to  Pneumo-Hydrothorax,        .        .        .        .111 

(o)  Succussion, Ill 

(b)  Metallic  Tinkle, .112 

(c)  The  Lung  Fistula  Sound 112 


CHAPTER  V. 

AUSCULTATION   OF   THE   HEART. 

1.  The  VAt-VK  Areas, 113 

2.  Normal  Heart  Sounds,         .         .         .        .  .         .        .         .114 

3.  MoniFICATlONS    IN    THE    iNTEXSrrY   OF    THE    HeART    SoUXDS,    .              .             .  116 

(a)  Mitral  First  Sound, 117 

1.  Shortening, 117 

2.  Doubling, 118 

(b)  The  Second  Sounds  at  the  Base  of  the  Heart,          .        .         .     •    .  118 

1.  Physiological  Variations, 118 

2.  Pathological  Variations,         .         .         .         .         .         .         .  120 

(a)  Accentuation  of  Pulmonic  Second  Sound,     .         .         .  120 

(6)  Weakening  of  Pulmonic  Second  Sound,        .         .         .  121 

(c)  Accentuation  of  the  Aortic  Second  Sound,    .        .         .  121 

(d)  Weakening  of  the  Aortic  Second  Sound,      .        .         .  121 

(e)  Accentuation  of  Both  Second  Sounds,  ....  122 
{/)  Summary 122 

(c)  Modifications  in  Rhythm  of  Cardiac  Sounds  and  Doubling  of  Sec- 

ond Sound.s, 123 

(d)  Metallic  Quality  of  the  Heart  Sounds, 124 

(e)  •'  Muffled  »  Heart  Sounds, 124 

4.  SoL'NDS  Audible  Over  the  Peripheral  Vessels,       ....  124 

(a)  Arterial  Sounds, 124 

(b)  Venous  Sounds, 126 


TABLE  OF  CONTENTS. 


XI 


CHAPTER  VI. 

(Auscultation  of  the  Heart  Continued.) 

CARDIAC   MURMURS. 


I.  Terminology,       .... 

1.  Mode  of  Production, 

2.  Place  of  Murmui's  in  Ihe  Cardiac 

3.  Point  of  Maximum  Intensity, 

4.  Area  of  Transmission,  . 

5.  Effects  of  Respiration,  Exertion, 

6.  Intensity,  Quality,  and  Length, 

7.  Relation  to  Heart  Sounds,. 

8.  Metamorphosis  of  Murmurs, 
II.  Functional  Murmurs, 

III.  Cardiorespiratory  Murmurs, 

IV.  Venous  Murmurs,        ... 
V.  Arterial  Murmurs,    . 


Cycl 


and  Position, 


page 

.  126 

.  126 

.  128 

.  129 

.  130 

.  135 
132-135 

.  135 

.  136 

.  136 

.  138 

.  139 

.  140 


PAKT  11. 

DISEASES   OF   THE  HEAET. 
CHAPTER  VII. 

VALVULAR   LESIONS. 

1.  Valvular  and  Parietal  Disease,        .         .         .         . 

2.  The  Establishment  and  Failure  of  Compensation, 

3.  Hypertrophy  and  Dilatation, 

4.  Valvular  Disease, 

I.  Mitral  Regurgitation, 

(a)  Pre-compensatory  Stage, 

(b)  Stage  of  Compensation,   . 

(c)  Stage  of  Failing  Compensation, 

(d)  Differential  Diagnosis,    . 
II.  Mitral  Stenosis, 

1.  First  Stage, 

2.  Second  Stage,  . 

3.  Third  Stage,     . 

4.  Differential  Diagnosis,    . 
III.  Aortic  Regurgitation, 

1.  Inspection, 


141 
144 
146 
151 
151 
153 
154 
158 
159 
161 
163 
165 
166 
167 
170 
171 


Xll 


TABLE  OF  CONTENTS. 


PAOE 

(a)  Arterial  Jerking, 172 

(6)  Capillaiy  Pulsation         .......  173 

2.  Palpation, 174 

3.  Percussion, 175 

4.  Auscultation, 175 

5.  Suiumaiy  and  Differential  Diagnosis, 178 

6.  Prognosis 179 

7.  Complications, 179 

IV.  Aortic  Stenosis 180 

1.  (a)  The  Murmur, 181 

(b)  The  Pulse. 183 

(c)  The  Thrill, 184 

(d)  Feeble  Aortic  Second  Sound 184 

2.  Differential  Diagnosis, 184 

V.  Tricuspid  Regurgitation, 187 

1.  (a)  The  Muruuu-, 188 

(b)  Venous  Pulsation, 188 

(c)  Cardiac  Dilatation, 189 

(d)  Feeble  Pulmonic  Second  Sound 189 

2.  Differential  Diagnosis, 190 

VI.  Tricuspid  Stenosis,            191 

VII.  Pulmonary  Regurgitation. 192 

VIII.  Pulmonary  Stenosis, 193 

IX.  Combined  Valvular  Lesions, 194 

(a)  Double  Mitral  Di.se;vsc, 195 

(6)  Aortic  and  Mitral  Regurgitation 196 

(c)  Aortic  Stenosis  and  Regurgitation. 197 

CHAPTER   YIII. 


II. 


PARIETAL  DISEASE   AND   CARDIAC   NEUROSES. 

AcLTE  Myocarditis, 
1    Acute  Moycarditis. 

2.  Chronic  Myocarditis. 

3.  Fatty  Overgrowth. 

4.  Fatty  Degeneratioi-. 
Cardiac  Neuroses, 

1.  Tachycardia. 

2.  Bradycardia, 

3.  Arrhythmia, 

4.  Palpitation,  . 

5.  Congenital  Heart  Disease, 


.  198 
.  198 
.  199 
.  201 
.  201 
.  202 
.  202 
.  203 
.  204 
.  205 
.  206 


TABLE  OF  CONTENTS.  xiil 

CHAPTER    IX. 
DISEASES  OF  THE  PERICARDIUM. 

>  PAGE 

I.  Pericarditis, 209 

(a)  Dry  or  Fibrinous, 209 

(6)  Pericardial  Effusion, 212 

1.  The  Area  of  Dulness, 213 

2.  The  Cardiac  Impulse  and  the  Pulse, 214 

a.  Pressure  Signs, 215 

(c)  Adherent  Pericardium, 216 

1.  Retraction  of  Interspaces, 217 

2.  Limitation  of  Respiratory  Movements,         ....  217 

3.  Absence  of  Cardiac  Displacement  with  Change  of  Position,  217 

4.  Hypertrophy  and  Dilatation  not  otherwise  Explained,         .  217 

5.  Capsular  Cirrhosis  of  the  Liver, 218 

II.  Hydropkricardium  and  Pneumopericaukium,    .....  219 

CHAPTER  X. 
THORACIC  ANEURISM. 

1.  Abnormal  Pulsation, 220 

2.  Tumor, 221 

3.  Thrill 222 

4.  Diastolic  Shock, 222 

5.  Tracheal  Tug, 223 

6.  Pressure  Signs 224 

7.  Percussion  Dulness, 224 

8.  Auscultation, 225 

(a)  Murmurs, 225 

(b)  Diastolic  Shock  Sound, 226 

9.  Radioscopy, 227 

10.  Summary 227 

11.  Diagnosis 229 


PART   III. 

DISEASES   OF   THE   LUNGS   AND   PLEURA. 

CHAPTER  XI. 
BRONCHITIS,   PNEUMONIA,  TUBERCULOSIS. 

1.  Tracheitis, 233 

2.  Bronchitis, 233 


XIV 


TABLE  OF  CONTENTS. 


PACK 

(a)  Physical  Signs, 234 

(6)  Differential  Diagnosis 235 

3.  Croupous  Pneumonia,    ..........  237 

(a)  Inspection 237 

(6)  Palpation 238 

(c)  Percussion, 238 

(d)  Auscultation, 239 

(e)  Summary, 242 

(/)  Differential  Diagnosis, 242 

4.  Bron'cho-Pneumoxia,      ..........  244 

5.  Pulmonary  Tuberculosis,     .........  245 

(a)  Incipient  Tubei-culosis, 245 

(6)  Moderately  Advanced  Cases, 249 

(c)  Advanced  Phthisis 252 

(d)  Anomalous  Forms  of  Pulmonary  Tuberculosis 256 


CHAPTER   XII. 


(Diseases  of  the  Lungs,  Continued.) 

1.  Emphtse-ma,     ..... 

(a)  Small-Lunged  Emphysema,    . 
(6)  Large-Lunged  Emphysema 

(c)  Emphysema  with  Bronchitis  and  Asthma, 

(d)  Interstitial  Emphysema, 

(e)  Complementary  Emphysema, 
(/)  Acute  Pulmonary  Tympanites, 

2.  Bronchial  Asthma, 

3.  Syphilis  of  thk  Lung, 

4.  Bronchiectasis,     .... 

5.  Cirrhosis  of  the  Lung, 


258 
258 
258 
261 
262 
262 
262 
263 
264 
264 
265 


CHAPTER   XIII. 

DISEASES  AFFECTING  THE  PLEURAL   CAVITY. 

I.  Hydrothorax, 266 

II.  Pneumothorax, 266 

III.  Pneumohydrothorax  and  Pneumopyothorax, 268 

Differential  Diagnosis  of  Pneumothorax  and  Pneumohydrothorax,     .  270 

IV.  Pleurisy 271 

1.  Dry  Pleurisy 271 


TABLE  OF  CONTENTS.  xv 

PAGE 

2.  Pleuritic  Effusion, 273 

(a)  Percussion, 273 

(6)  Auscultation 279 

(c)  Inspection  and  Palpation, 281 

3.  Pleural  Thickening, 283 

4.  Encapsulated  Pleural  Effusions, 283 

5.  Pulsating  Pleurisy  and  Empyema  Necessitatis, 284 

6.  Differential  Diagnosis  of  Pleural  Effusions, 284 

CHAPTER  XIV. 

ABSCESS,  GANGRENE  AND  CANCER  OF  THE  LUNG,  PULMONARY 
ATELECTASIS,  (EDEMA  AND  HYPOSTATIC  CONGESTION. 

1.  Abscess  and  Gangrene  of  the  Lung 290 

2.  Cancer  of  the  Lung, 291 

3.  Atelectasis, 292 

4.  CEdema  and  Hypostatic  Congestion, 293 

APPENDICES. 

Appendix  A. — -Diseases  of  the  Mediastinum 293 

1.  Mediastinal  Tumors, 293 

2.  Mediastinitis, 295 

3.  Tuberculosis  of  Mediastinal  Glands, 296 

Appendix  B. — Acutk  Eni>ocarditis.          .......  296 

Appendix  C. — Examination  of  Infant's  Chests,    .....  297 

Appendix  D. — Radioscopy  of  thk  Chest, 298 

Appendix  E. — The  Sphygmograph 305 


PHYSICAL   DIAGNOSIS 


OF 


DISEASES   OF  THE  CHEST. 


INTRODUCTION. 

I.  Methods  of  Examining  the  Thoracic  Organs. 

To  cany  out  a  thorough  examination  of  the  chest  we  do  five 
things:  1.  We  look  at  it;  technically  called  "inspection."  2.  We 
feel  of  it;  technically  called  "palpation."  3.  We  listen  to  the 
sounds  produced  by  striking  it;  technically  called  "percussion." 
4.  We  listen  to  the  sounds  produced  within  it  by  physiological  or 
pathological  processes;  technically  called  "auscultation."  5.  We 
study  pictures  thrown  on  the  fluoroscopic  screen  or  on  a  photo- 
graphic plate  by  the  Roentgen  rays  as  they  traverse  the  chest; 
technically  called  "radioscopy." 

Measuring  the  dimensions  or  the  movements  of  the  chest  ("  men- 
suration ")  is  often  mentioned  as  co-ordinate  with  the  above  meth- 
ods, but  it  yields  very  little  information  of  practical  value,  and  is 
at  present  very  little  used. 

The  data  obtained  by  examining  the  sputa,  blood,  and  urine  are 
frequently  of  great  value  in  helping  us  to  interpret  the  signs  re- 
vealed by  examination  of  the  chest,  but  do  not  fall  within  the 
scope  of  this  book.  Accordingly,  I  shall  confine  myself  in  the 
first  part  of  this  book  to  a  description  of  the  methods  of  inspect- 
ing, palpating,  percussing,  and  auscultating  the  chest,  with  a  brief 
account  of  the  physical  signs  which  we  have  learned  to  appreciate 
by  the  use  of  these  methods.  (For  radioscopy,  see  Appendix.) 
1 


PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 


Without  some  knowledge  of  the  regional  anatomy  of  the  chest 
no  intelligent  investigation  of  the  condition  of  the  thoracic  organs 
can  be  carried  on.  Accordingly,  I  shall  begin  by  recalling  very 
briefly  some  of  the  most  essential  anatomical  relations. 

II.   Regioxal  Axatomy  of  the  Chest. 

It  seems  to  me  a  mistake  to  divide  the  chest  into  arbitrary  por- 
tions and  to  describe  physical  signs  with  reference  to  such  di\'ision. 
The  seat  of  any  lesion  can  best  be  described 
by  giving  its  relation  to  the  clavicle,  ster- 
num, or  ribs  on  the  front  and  sides  of  the 
chest,  and  to  the  scapulae  and  ribs  behmd. 
Thus  we  may  speak  of  rales  as  heard  "  above 
the  left  clavicle  in  front,"  "below  the  right 
scapula  behind, "  "between  the  seventh  and 
ninth  ribs  in  the  axilla,"  and  so  on.  When 
we  want  to  state  more  exactly  what  part  of 
the  axilla  anteroposteriorly  is  affected,  we 
may  refer  to  the  "  mid-axillary  line "  (see 
Fig.  1) ;  or  better,  we  may  place  the  lesion 
by  measuring  the  number  of  centimetres  or 
inches  from  the  median  line  of  the  sternum. 
In  a  similar  way  the  place  of  the  apex  im- 
pulse of  the  heart  (whether  in  the  normal 
situation  or  farther  toward  the  axilla)  can  be 
determined  by  measuring  from  the  median 
line  of  the  sternum.  Measurements  refer- 
ring to  the  nipple  are  entirely  useless  in 
women  and  not  very  reliable  in  men.  It  is 
better  to  measure  as  above. 

If,  then,  we  confine  ourselves  chiefly  to 
the  bones  of  the. chest  as  landmarks,  and 
fix,  with  reference  to  them,  the  position  of  any  portion  of  the  in- 
ternal organs  which  we  desire  to  study,  it  becomes  unnecessary  to 
memorize  any  technical  terms  or  to  learn  the  position  of  any  arbi- 
trary lines  and  divisions  such  as  are  frequently  forced  upon  the 


Fig.  l.-The    Mld-Axlllary 
Line. 


INTRODUCTION.  3 

student.     The  only  points  which  it  is  necessary  to  memorize  once 
for  all  are  : 

1.  The  position  of  the  heart,  lungs,  liver,  and  spleen  with  ref- 
erence to  the  bones  of  the  chest. 

2.  The  position  of  certain  points  which  experience  has  taught 
us  have  a  certain  value  in  physical  diagnosis.  I  mean  (a)  the 
so-called  "  valve  areas  "  of  the  heart,  which  do  not  correspond  to 
the  actual  position  of  the  valves,  for  reasons  to  be  explained  later 


/  fi'^(!yf/^^Zr\   'V^y^  ^^^i\  \     -  Upper  lobe  of  left 

Bight  auricle.  —I jl"  (f^^^^ii/  ,^^^^^^iT*N ^"  ^®°*^^'*'' 

\  ^®^'^/     ^^\^^^3^~/  Lower  lobe  of  left 

\  ^^  ^  \  ""  stomach. 


Fig.  2.— Position  of  the  Heart,  Lungs,  Liver,  and  Stomach.  The  dotted  lines  correspond  to  the 
outlines  of  the  lung ;  the  heavy  continuous  line  represents  the  heart ;  while  the  position  of 
the  liver  and  of  the  lower  border  of  the  stomach  is  indicated  by  light  continuous  lines.  The 
ribs  are  numbered. 

on,  and  (b)  the  percussion  outlines  of  the  heart,  liver,  and  spleen. 
These  outlines  do  not  correspond  in  size  with  the  actual  dimensions 
of  the  organs  within,  yet  there  is  a  definite  relation  between  the  two 
which  remains  relatively  constant,  so  that  we  can  infer  the  size  of 
the  organ  itself  from  the  outlines  which  we  determine  by  percus- 
sion. The  position  of  the  organs  themselves  is  shown  in  Figs.  2, 
3,  and  4.  It  will  be  noticed  in  Fig.  2  that  the  lungs  extend  up 
above  the  clavicles  and  overlap  the  liver  and  the  heart — facts  of 
considerable  importance  in  the  physical  examination  of  these  or- 
gans, as  will  be  later  seen.     It  is  also  to  be  noticed  how  small 


4         PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

a  portion  of  the  stomach  is  directly  accessible  to  physical  examina- 
tion, the  larger  part  of  it  lying  behind  the  ribs  and  covered  by  the 


^\    ^^i-  Upper  lobe. 


^,  Lower  lobe. 


Spleen. 

Lower  lobe. 


Upper 
lobe. 


Middle 
lobe. 


_  Liver 


Fig.  3.— Position  of  the  Left  Lung  from  the       Fig.  4.— Position  of  the  Right  Lung  from  the 
Sides  and  of  the  Spleen.  Side,  and  of  the  Liver. 

liver.     The  normal  pancreas  and  kidneys  are  j^ractieally  inacces- 
sible to  physical  examination. 

The  percussion  outlines — corresponding  to  those  portions  of 
the  heart,  liver,  and  spleen  which  lie  immediately  beneath  the 
chest  walls — will  be  illustrated  in  the  section  on  Percussion  (see 
page  58). 


PART  I. 

TECHNIQUE  AND  GENERAL  DIAGNOSIS. 


INSPECTION. 


Much  may  be  learned  by  a  careful  inspection  of  all  parts  of  the 
cbest,  but  only  in  case  the  clothes  are  wholly  removed.  A  good 
light  is  essential,  and  this  does  not  always  mean  a  direct  light ;  for 
example,  when  examining  the  front  of  the  chest  it  is  often  better 
to  have  the  patient  stand  with  his  side  to  the  window  so  that  the 
light  strikes  obliquely  across  the  chest,  accenting  every  depression 
and  making  every  pulsation  a  moving  shadow.  In  searching  for 
abnormal  pulsations,  this  oblique  light  is  especially  important. 

In  examining  the  thorax  we  look  for  the  following  j)oints : 

1.  The  size. 

2.  The  general  shape  and  nutrition. 

3.  Local  deformities  or  tumors. 

4.  The  respiratory  movements  of  the  chest  walls. 

5.  The  respiratory  movements  of  the  diaphragm. 

6.  The  normal  cardiac  movements. 

7.  Abnormal  pulsations  (arterial,  venous,  or  capillary). 

8.  The  peripheral  vessels. 

9.  The  color  and  condition  of  the  skin  and  mucous  membranes. 

10.  The  presence  or  absence  of  glandular  enlargement. 

I.   Size. 

Small  chests  are  seen  in  patients  who  have  been  long  in  bed 
from  whatever  cause ;  also  in  those  who  have  suffered  in  infancy 
from  rickets,  adenoid  growths  in  the  naso-pharynx,  or  a  combina- 
tion of  the  two  diseases.  Abnormally  large  chests  are  seen  chiefly 
in  emphysema.     Of  course  the  chests  of  healthy  individuals  vary 


6         PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

a  great  deal  in  size  at  any  given  age,  and  I  have  been  referring  in 
the  last  sentences  only  to  variations  greater  than  those  normally 
found. 

II.  Shape. 

There  are  marked  differences  in  shape  between  the  child's  and 
the  adult's  chest  in  health.     A  child's  trunk,  as  compared  with 


Fig.  5.— Funnel  Breast. 

that  of  an  adult,  is  far  more  nearly  cylindrical ;  that  is,  the  antero- 
posterior diameter  is  nearly  as  great  as  the  lateral.  The  adult's 
chest  is  distinctly  flattened  from  before  backward,  although  indi- 
vidual variations  in  this  respect  are  considerable,  as  Woods  Hutch- 
inson has  shown. 

In  childhood  the  commonest  pathological  modifications  are  due 


INSPECTION.  ' 

to  rickets ;  iu  middle  and  later  life  to  emphysema,  phthisis,  or  old 
pleuritic  disease. 

{a)  The  Rachitic  Chest. 

The  sternum  generally  projects  {''pigeon  breast"),  but  in  some 
cases,  especially  when  rickets  is  combiued  with  adenoid  hyper- 
trophy, there  may  be  a  depression  at  the  root  of  the  sternum  re- 
sulting in  the  condition  known  as  "fnn7iel  breast "  '   (Figs.  5  and  6). 


^^i 


Fig.  6.— Funnel  Breast. 

The  sides  of  the  chest  are  compressed  laterally  and  slope  in  to  meet 
the  sternum  as  the  sides  of  a  ship  slope  down  to  meet  the  keel 
(pectus  carinatum)  (Figs.  8,  9  and  10).  From  the  origin  of  the  eusi- 
form  cartilage  a  depression  or  groove  is  to  be  seen  runnuig  down- 
ward and  outward  to  the  axilla  and  corresponding  nearly  to  the 
attachment  of  the  diaphragm.  This  is  sometimes  spoken  of  as 
"  Harrison's  groove  "  (Figs.  11  and  12).  The  lower  margin  of  the  ribs 
1  In  some  cases  this  condition  appears  to  be  congenital. 


8 


PHYSICAL  DIAGNOSIS   OF  DISEASES  OF  THE  CHEST. 


in  front  often  flares  out,  owing  to  the  enlargement  of  the  liver  and 
spleen  below  and  the  pull  of  the  diaphragm  above.  Along  the  line 
of  the  chondro-costal  articulation  there  is  to  be  felt,  and  sometimes 


Fig.  7.— Acquired  Depression  at  the  Root  of  the  Ensiform  Cartilage.  The  patient  is  a  shoe- 
maker of  seventy,  who  has  all  his  life  pressed  against  his  breast  bone  the  shoe  on  which 
he  worked. 

seen,  a  line  of  eminences  or  swellings,  to  which  the  name  of  "ra- 
chitic rosarij  "  has  been  given  (see  Fig.  13). 

(/y)  The  ''Paralytic  Thorax." 

Fig.  14  conveys  a  better  idea  of  this  form  of  chest  than  any 
description.  The  normal  anteroposterior  flattening  is  exaggerated 
so  that  such  persons  are  often  spoken  of  as  "flat-chested."  The 
clavicles  are  very  prominent,   owing  to  falling  in  of  the  tissues 


INSPECTION.  9 

above  and  below  them;  the  shoulders  are  stooping,  the  scapulae 
prominent,  and  the  neck  is  generally  long.  The  angle  where  the 
ribs  meet  at  the  ensif  orm  cartilage,  the  so-called  "  costal  angle, "  is  in 
such  cases  very  sharp.  This  type  of  chest  has  often  been  supposed 
to  be  characteristic  of  phthisis,  but  may  be  found  in  persons  with 
perfectly  healthy  lungs.     On  the  other  hand,  phthisis  frequently 


Fig.  8.— Pigeon  Breast. 

exists  iu  persons  with  normally  shaped  chests  or  with  abnormally 
deep  chests  (Woods  Hutchinson).     (See  Fig.  128,  page  251.) 

(c)  The  ''Barrel  Chest." 

Nothing  is  less  like  a  barrel  than  the  ''barrel  chest."  Its  most 
striking  characteristic  is  its  greatly  increased  anteroposterior  diam- 
eter, so  that  it  approaches  the  form  of  the  infant's  chest.  The 
costal  angle  is  very  obtuse,  the  shoulders  are  high,  and  the  neck 
is  short.  The  respiratory  movements  of  the  barrel  chest  will  be 
spoken  of  later  (see  Figs.  15  and  16). 


10       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

Xutrltion  of  the  Cltest  Walls. 

Emaciation  is  readily  appreciated  by  inspection.  The  ribs  are 
unusually  prominent,  the  scapulae  stand  out,  and  the  clavicles  pro- 
ject.    All  this  may  be  seen  independently  of  any  change  in  the 


Fig.  9.— Pigeon  Breast. 


shape  of  the  chest  such  as  was  described  above  under  the  title  of 
Paralytic  Thorax.  Tuberculosis  of  the  apices  of  the  lungs  may 
produce  a  marked  falling  in  of  the  tissues  above  and  below  the 
clavicle  independent  of  any  emaciation  of  the  chest  itself. 


INSPECTION. 


11 


Fig.  10.— Pigeon  Breast. 


12       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

III.   Deformities. 

The  abnormalities  just  enumerated  are  symmetrical  and  affect 
the  whole  thorax.  Under  the  head  of  Deformities,  I  shall  consider 
chiefly  such  abnormalities  as  affect  particular  portions  of  the  chest 
and  not  the  thorax  as  a  whole. 

(a)   Spinal   Curvatures  and  Twists. 

A  good  view  of  the  patient's  back  brings  out  best  the  lesser  de- 
grees of  lateral  curvature,  which  are  not  at  all  infrequent  in  persons 


who  are  not  aware  of  them.  Slight  degrees  of  deformity  are  best 
seen  by  marking  with  a  skin-pencil  the  position  of  the  spinous  proc- 
esses (see  Fig.  18).  The  more  marked  cases  of  lateral  curvature, 
which  are  usually  accompanied  by  a  certain  amoimt  of  twisting, 
give  rise  to  considerable  displacement  of  the  thoracic  organs  and 
render  unreliable  the  usual  bony  landmarks,  with  reference  to 
which  we  judge  of  the  position  of  the  intrathoracic  organs.  By 
such  deformities  the  apex  of  the  heart  may  be  pushed  up  into  the 


INSPECTION, 


13 


Fig.  12.— Harrison's  (iroove. 

fourth  space  or  out  into  the  axilla,  or  portions  of  the  lungs  may 
be  compressed  and  made  atelectatic. 

I.  The  bulging  on  the  convex  side  of  the  curve  may  simulate 
an  aneurisnial  tumor. 

II.  Pott's  disease  of  the  spine  should  be  looked  for  as  a  part 


Fig.  13.— Remains  of  Rachitic  Rosary  in  a  Boy  of  Seventeen. 


14       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 


of  the  routine  inspection  of  the  chest.     It  is  sometimes  better  felt 
than  seen. 

III.  Abnormal  rigidity  of  the  spine,  due  to  spondylitis  defor- 
mans, is  to  be  recognized  by  watching  the  movements  of  the  spinal 
column  as  the  patient  bends  forward  and  back.  Where  the  verte- 
bi"8e  are  locked  together,  as  occurs  in  moderately  advanced  cases  of 

this  disease,  the  spine  is 
maintained  rigidly  stiff,  in- 
dependent of  muscular  sup- 
port. A  siniilar  stiffness  of 
the  spine  may  also  be  seen 
in  early  Pott's  disease.  It 
is  here  due  mostly  to  mus- 
cular spasm. 

[b)   Flatteninr/  of  One  Side 
of  the  Chest. 

In  chronic  phthisis,  cir- 
rhosis of  the  lung,  or  long- 
standing pleuritic  effusion, 
marked    falling    in   of  one 
side  of  the  chest  is  often  to 
be  seen.     This  may  be  ap- 
parent   in    the    upper   and 
front    portion,    beneath  the 
clavicle,  or  in  the  axilla,  or 
in  both  situations  (see  Figs. 
14  and  20) .     The  shrinkage  of  the  affected  side  is  made  more  ob- 
vious by  contrast  with  the  compensatory  hypertrophy  of  the  sound 
lung,  which  makes  the  sound  side  unusually  full  and  prominent. 


Fitt.  U.— The  Paralytic  Thorax. 


(c)  Prominence  of  One  Side  of  the  Chest. 

In  pneumothorax  or  pleural  effusions,  and  sometimes  in  malig- 
nant disease  of  the  lung  or  pleura,  there  is  a  marked  increase  in  the 
size  of  the  affected  side  of  the  chest.     Very  rarely  emphysema 


INSPECTION. 


16 


may  affect  one  lung  predominantly.     In  pneumothorax  or  jDleuritic 

effusion  we  usually  see,  in  addition  to  the  above  enlargement  of  the 

affected  side,  a  smoothing  out  of 

the  intercostal  depressions  so  that 

the  surface  of  that  side  is  much 

more  uniform  than  the  other  side. 

Bulging  of  the  interspaces  from 

great  pressure  within  the  chest  is 

said  to  occur.     I  have  never  seen 

it  and  am  somewhat  sceptical  as 

to  its  occurrence. 

(cl)  Local  Prominences. 

In  nearly  one-quarter  of  all 
healthy  chests  that  part  of  the 
thoracic  wall  which  overlies  the 
heart  (the  so-called  "precordial 
region ")  is  abnormally  promi- 
nent. The  cause  of  this  condi- 
tion is  much  disputed.  A  similar 
prominence  may  be  brought  about 
in  children,  whose  thoracic  bones 
are  very  flexible  (and  occasionally 
in  older  patients) ,  by  the  outward 
pressure  of  an  enlarged  heart  or 
of  an  effusion  in  the  pericardial 
sac.  The  prominences  due  to 
spinal  curvature  have  been  al- 
ready mentioned.  Less  common 
causes  of  local  prominence  are : 

1,  Aneurism  of  the  arch  of 
the  aorta. 

2.  Tumor   of  the  chest  wall 

(lipoma,  sarcoma,  gumma)  or  of  the  lung,  mediastinum,  or  of  the 
thoracic  glands  pressing  their  way  outward. 


Fig.  15.— Barrel  Chest  in  a  Case  of  Bron- 
chial Asthma  (set.  13). 


16       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

3.  "  Cold  abscess  "  (tuberculosis)  of  a  rib  or  of  the  sternum. 

4.  Empyema  perforating  the  chest  wall,  the  so-called  "  empyema 
necessitatis." 

IV.  The  Respiratoky  Movements. 


(a)  Normal  Respiration. 

During  normal  respiration,  one  sees  the  ribs  move  outward  and 
upward  with  inspiration,  and  downward  and  inward  with  expira- 
tion. Possibly  one  catches  some 
hint  of  the  movements  of  the 
diaphragm  at  the  epigastrium. 
In  men,  diaphragmatic  breath- 
ing is  more  marked,  while  in 
women  breathing  is  mostly  of 
the  "  costal  type  " ;  that  is,  is 
done  by  the  intercostal  muscles. 
In  certain  diseases  an  exaggera- 
tion of  the  costal  or  of  the  dia- 
phragmatic type  of  breathing 
may  be  seen.  In  emphysema, 
for  example,  and  in  some  cases 
of  asthma,  the  ribs  move  very 
little,  and  most  of  the  work  of 
respiration  is  performed  by  the 
diaphragm,  whose  pull  upon  the 
lower  ribs  can  sometimes  be  distinctly  seen  during  inspiration.  On 
the  other  hand,  when  the  movements  of  the  diaphragm  are  impeded 
by  the  presence  of  fluid  or  a  solid  tumor,  as  in  cirrhosis  of  the 
liver  or  leukaemia,  the  breathing  has  largely  to  be  performed  by  the 
ribs,  and  becomes,  as  we  say,  costal  in  type  (see  below,  j).  19). 


Fig.  16.— Barrel    Chest.    Cbronic  bronchitis 
and  emphysema. 


{h)  Anomalies  of  Expansion. 

If  we  watch  the  patient  while  he  takes  a  full  breath,  we  may 
notice  certain  variations  from  the  normal  type  of  respiratory  move- 


INSPECTION. 


17 


ments,     We  may  see:  (1)  Diminished  expansion  of  one  side  (as  a 
whole,  or  at  the  apex).     (2)  Increased  expansion  of  one  side. 

(1)  If  diminished  expansion  of  one  side  is  due  to  pleuritic  effusion, 
pneumothorax,  or  solid  tumor  of  the  lung  or  pleura,  the  affected- 
side  is  usually  distended  as  well  as  immobile.     When,  on  the  other 


Fig. 


I".— Severe  Luteml  Curvature  (Un- 
treated) . 


FIG. 


]S.— Lateral  Curvature  Three  Weeks 
After  Correction. 


hand,  the  lung  is  retracted  or  bound  down  by  adhesions,  as  in 
phthisis,  old  pleurisy,  occlusion  of  the  bronchus,  or  from  the  pres- 
sure of  an  aneurism,  we  have  immobility  combined  with  a  retraction 
of  the  affected  side.  In  tuberculous  disease  at  the  apex  of  the 
lungs,  we  may  see  one  side  or  both  sides  fail  to  expand  at  the  top. 
Restriction  of  the  motion  of  one  side  of  the  chest  may  also  be  due 


18       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 


to  pressure  from  below  the  diaphragm.     An  enlarged  liver  or  spleen 
and  tumors  of  the  hepatic  or  splenic  region  may  in  this  Avay  prevent 
the  normal  expansion  of  one  or  the  other  side  of  the  thorax.     Oc- 
casionally a  hemiplegia  or  a  unilat- 
^^^^^  Cral    paralysis     of    the    diaphragm 

^^^^^^^^  results  in  diminished  movement  of 

^^^^^^^H^  side  of  the  chest. 

^^^^^^^^^V  (2)   Increased   expansion   of   one 

^m^^HHI  side  of  the  chest  is  observed  princi- 

^^^^V^kI  P^lly  ^s  a  compensatory  or  vicarious 

^^  overfunctioning   of  that  side  when 

the  other  side  of  the  chest  is  thrown 
out  of  use  by  a  large  pleuritic  effu- 
sion, by  pneumothorax,  long-stand- 
ing pleurisy  with  contraction,  or 
other  causes. 


Fig.  19.— Lateral  Cun-ature  Before  Cor- 
rection. 


(r)  Dyspnoea 

This  term  is  often  used  rather 
loosely  to  include :  (1)  Difficult 
breatliing,  Avhether  rapid  or  slow. 
(2)  Unusually  deep  breathing, 
whether  difficult  or  not.  (3)  Eapid 
breathing. 

True  dyspnoea  or  difficult  breath- 
ing is  almost  always  rapid  as  Avell, 
and  does  not  differ  at  all  from  the 
well-known  phenomenon  of  being  **  out  of  breath  "  after  a  hard  run 
OP  any  violent  exertion.  Conceive  these  conditions  as  persisting 
over  hours  or  days,  and  we  have  the  phenomenon  known  as  dysp- 
noea. The  breathing  is  not  only  thick  but  labored ;  that  is,  per- 
formed with  difficulty,  and  imusual  muscles,  not  ordinarily  called 
upon  for  respiration,  come  into  play  and  are  seen  working  above 
the  clavicle  and  elsewhere.  More  or  less  distress  is  generally  ex- 
pressed in  the  face,  and  there  is  often  a  blueness  of  the  lips  or  a 
dusky  color  throughout  the  face.     The  commonest  causes  of  dysp- 


INSPECTION. 


19 


noea    are    the    various  forms   of  heart    disease,   pneumonia,  large 
pleuritic  effusion,  emphysema,  asthma,  and  phthisis. 

Dyspnoea  may  affect  esj)ecially  insjjiration,  as,  for  example, 
when  a  foreign  body  lodges  in  the  larynx,  or  in  ordinary  "croup." 
In  such  cases  we  speak  of  '"'' inspiratonj  dijsjincea,^^  distinguishing  it 
from  "  expiratory  dyspnoia  "  such  as  occurs  in  asthma  and  emphy- 
sema. In  the  latter  condition  the  breath  seems  to  enter  the  chest 
readily,  but  the  difficulty  is  to  get  it  out  again.  Expiration  is 
greatly  prolonged  and  often  noisy. 

Combined  types  also  occur  in  which  both  respiratory  acts  are 
difficult. 

Abnormally  deep  and  full  respirntion,  without  any  appearance  of 
difficulty  in  the  process,  is  sometimes  seen  near  the  fatal  termina- 
tion of  cases  of  diabetes, 
the  so  -  called  diabetic 
dyspnoea. 

Simjjle  rapndity  of 
hreathing  should  be  dis- 
tinguished from  dyspnoea 
of  any  type.  In  adults 
the  normal  rate  of  respi- 
ration is  about  22  per 
minute.  In  children,  it  is 
considerably  quicker  and 
more  irregular.  It  is  not 
desirable  to  attempt  here 
to  enumerate  all  the 
causes  which  may  lead  to 
a  quickening  of  the  respi- 
ration. Among  the  com- 
moner are  muscular  exer- 
tion, emotional  disturb- 
ance, diseases  of  the  heart  and  lungs,  and  fluid  or  solid  accumula- 
tions below  the  diaphragm,  which  push  up  that  muscle  and  cause  it 
to  encroach  abnormally  upon  the  thoracic  cavity.  Most  of  the  in- 
fectious fevers  are  also  apt  to  be  accompanied  by  quickened  breath- 


FiG.  20.— Contraction  of  Left  Chest.    Empyema. 


20       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 


ing,  especially  but  not  exclusively  when  the  fever  is  associated  with 
a  disease  of  the  heart,  lung,  pleura,  or  pericardium. 

Sucking-in  of  the  interspaces  in  the  lower  axillary  regions  or 

below  the  clavicles  may 
be  seen  in  connection 
with  dyspnoea  Avhen- 
ever  the  lungs  are  pre- 
vented by  some  cause 
from  properly  expand- 
ing during  inspiration. 
^Negative  pressure  i  s 
thus  produced  within 
_the  chest,  and  the  at- 
mospheric pressure 
without  pushes  in  the 
more  elastic  parts  of 
the  thorax.  This  phe- 
nomenon is  seen  in  col- 
lapse or  atelectasis  of 
a  portion  or  the  whole 
of  a  lung,  such  as  may 
occur  in  obstruction  at 
the  glottis  (in  which 
case  both  sides  are 
equally  retracted)  o  r 
from  occlusion  of  a 
bronchus.  In  the  lat- 
ter event,  the  sucking-in  of  the  interspaces  diiring  inspiration  oc- 
curs only  on  the  affected  side.^ 

'  Slight  retraction  of  the  lower  interspaces  in  the  axilla  during  inspiration 
is  often  seen  in  health.     In  disease  this  phenomenon  is  greatly  exaggerated. 


Fig.  21.— Prominence  of  Right  Side.    Pleural  Effusion. 


INSPECTION.  21 

Y.  Changes  tx  the  Respiratory  Rhythm. 

{a)  Asthmatic  BreatJiing. 

In  asthma  the  normal  rhythm  is  reversed  and  the  expiration 
becomes  longer,  instead  of  shorter,  than  inspiration.  Inspiration 
may  be  represented  only  by  a  short  gasp,  while  expiration  becomes 
a  prolonged  wheeze  lasting  several  tunes  as  long  as  inspiration. 
Dyspnaa  is  usually  very  marked.  In  emphysema  we  get  very 
much  the  same  type  of  breathing  so  far  as  rhythm  is  concerned, 
biit  the  dyspnoea  is  not  usually  so  extreme  and  the  auxiliary  mus- 
cles of  respiration  are  not  so  apt  to  be  called  into  use.  In  many 
cases  of  emphysema  one  sees  the  thorax  move  all  as  one  piece,  "  en 
cnirasse,"  owing  to  a  senile  fixation  of  the  bones  of  the  thorax  from 
ossification  of  the  cartilaginous  portions.  In  hereditary  syphilis 
this  fixation  may  occur  in  j^outh  or  early  middle  age. 

(b)  Cheyne-Stokes  Breathing. 

An  anomaly  of  respiratory  rhythm  in  which  short,  recurrent 
paroxysms  of  dj'spnoea  are  preceded  and  followed  by  periods  in 
which  no  respiration  occurs  (apnoea).  If  we  represent  the  normal 
respiratory  movement  by  an  up-and-down  line,  as  seen  in  Fig.  22, 

Fici.  22.— Diagram  to  Represent  Normal  Breathlng-Khytliiii. 

the  Cheyne-Stokes  type  of  breathing  would  appear  as  in  Fig  23, 
The  period  of  apnoea  may  last  from  one  to  ten  seconds ;  then  short, 
shallow  respirations  begin  and  increase  rapidly,  both  in  volume  and 
in  rate,  imtil  a  maximiun  of  marked  dyspnoea  is  reached,  when  a 
diminution  in  the  rate  and  depth  of  the  act  begins,  and  the  patient 
gradually  returns  to  the  apnoeic  state  The  length  of  the  whole 
paroxysm  may  be  from  30  to  70  seconds  Durmg  the  apnoeic 
period  the  patient  is  apt  to  drop  asleep  for  a  few  seconds  and  the 
pupils  may  become  contracted      AMien  the  paroxysm  of  dyspnoea 


22       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

is -at  its  height,  he  is  apt  to  cough  and  shift  his  position  restlessly, 
or  in  case  the  whole  phenomenon  occurs  duruig  sleep  he  moves  un- 
easily in  his  sleep  at  this  period.  Modiiied  types  of  the  phenome- 
non also  occur,  in  which  there  is  a  rhythmic  increase  and  decrease 
in  the  depth  and  rapidity  of  respiration  but  without  any  interven- 
ing i^eriod  of  apnoea.  This  type  of  breathing  is  most  often  seen  in 
severe  cases  of  cardiac,  renal,  or  cerebral  disease.  It  is  generally 
more  marked  at  night  and  may  occur  only  at  that  time.  In  chil- 
dren it  appears  sometimes  to  be  physiological  during  sleep.     As  a 


Fig.  23.— Cheyne-Stokes  Respiration. 

rule,  it  is  a  sign  of  gi'ave  prognostic  significance,  but  patients  have 
been  known  to  recover  completely  after  weeks  or  even  months  of 
Cheyne-Stokes  breathing. 

(c)  Restrained  or  "  Catchy  "  Breathing. 

When  the  patient  has  a  "stitch  in  the  side,"  due  to  dry  pleu- 
risy, intercostal  neuralgia,  or  to  other  causes,  the  inspiration  may 
be  suddenly  interrupted  in  the  middle,  owmg  to  a  seizure  of  pain 
which  makes  the  patient  stop  breathing  as  quickly  as  he  can.  The 
same  conditions  may  produce  very  shallow  breathing  as  the  patient 
tries  to  avoid  the  pain  which  a  fall  inspiration  will  cause.  This 
type  of  restrained  breathing  is  clten  seen  in  pleurisy  and  pneumo- 
nia, and  in  the  latter  disease  expiration  is  often  accompanied  by 
a  little  moan  or  grunt  of  discomfort 

(d)  Shallow  and  irregular  hreathing  is  often  seen  in  states  of  pro- 
found unconsciousness  from  any  cause,  such  as  apoplexy  or  poison- 
ing. A  few  deep  respirations  may  be  followed  by  a  number  of 
shallow  and  irregular  ones.  AYhen  death  is  imminent  in  any  dis- 
ease, the  respiration  may  become  very  irregular  and  gasping,  and 
it  is  apt  to  be  accompanied  by  a  peculiar  nodding  movement  of  the 


INSPECTION.  23 

head,  the  chin  bemg  thrown  quickly  upward  during  inspiration,  and 
falling  slowly  during  expiration,  I  have  known  but  one  patient  to 
recover  after  this  type  of  breathing  had  set  in. 

After  severe  hemorrhage  the  breathing  may  be  of  a  aifjliing  tupe 
as  well  as  very  shallow. 

(e)  Stridulous  Breathing. 

A  high-pitched,  crowing  or  barking  sound  is  heard  during  inspi- 
ration when  there  is  obstruction  of  the  entrance  of  air  at  or  near 
the  glottis.  This  type  of  breathing  occurs  in  spasm  or  oedema  of 
the  glottis,  ''  croup,"  laryngismus  stridulus,  and  forms  the  "  Avhoop  " 
in  the  paroxysms  of  whooping-cough.  Laryngeal  or  tracheal  ob- 
structions due  to  foreign  bodies,  or  tumors  within  or  pressure  from 
without  the  air-tubes,  may  cause  a  similar  type  of  respiration.  It 
is  in  these  cases  especially  that  we  see  the  sucking-in  of  the  inter- 
spaces mentioned  above  (see  p.  20). 

VI.  Diaphragmatic  Movements. 

Litteii's  Phenomenon. 

The  normal  movements  of  the  diaphragm  may  be  rendered  vis- 
ible by  the  following  procedure,  suggested  by  Litten  in  1892:  The 
patient  lies  upon  his  back  with  the  chest  bared  and  the  feet  pointed 
directly  toward  a  window.  Cross  lights  must  be  altogether  ex- 
cluded by  darkening  any  other  windows  which  the  room  may  con- 
tain' (see  Fig.  24).  The  observer  stands  at  the  patient's  side 
and  asks  him  to  take  a  full  breath.  As  the  ribs  rise  with  the 
movement  of  inspiration,  a  short,  narrow  shadow  moves  down  along 
the  axilla  from  about  the  seventh  to  about  the  ninth  or  tenth  rib. 
During  the  expiration  the  shadow  rises  again  to  the  point  from 
which  it  started,  but  is  less  easily  seen.  This  phenomenon  is  to  be 
seen  on  both  sides  of  the  chest  and  sometimes  in  the  epigastrium. 

'  If  it  is  inconvenient  to  move  the  patient's  bed  into  the  proper  position 
with  relation  to  the  window,  or  if  the  foot-boai*d  interferes,  or  if  the  observa- 
tion has  to  be  made  after  dark,  a  dark  lantern  or  other  strong  light  held  at  the 
foot  of  the  bed  answers  very  well.  All  other  light  must,  of  course,  be  ex- 
cluded. 


24      PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

It  is  best  seen  iii  spare,  muscular  young  persons  of  either  sex,  and 
is  never  absent  in  health  except  in  those  who  are  very  fat,  or  who 
cannot  or  will  not  breathe  deeply.     The  latter  condition  occurs  in 


!<- 


Fig.  24.— Litten's  Diaphragm  Shadow.    Proper   position  of   patient  and   of   obsener. 
shadow  is  best  seen  near  L. 


The 


hysteria  and  in  some  very  stupid  persons  who  cannot  be  made  to 
understand  what  is  meant  by  a  full  breath.  In  the  observation  of 
several  thousand  cases,  I  have  never  knoAvn  it  absent  in  health 
except  under  these  conditions. 

In  normal  chests,  the  excursion  of  the  shadow  is  about  two  and 
a  half  inches;  with  very  forced  breathing  three  and  a  half  inches. 
The  mechanism  of  this  phenomenon  is  best  understood  by  imagin- 
ing a  coronal  section  of  the  thorax  as  seen  from  the  front  or  back 
(see  Fig.  25).  At  the  end  of  expiration,  the  diaphragm  lies 
flat  against  the  thorax  from  its  attachment  up  to  about  the  sixth 
rib.  During  inspiration  it  "j/eeJs  off"  as  it  descends  and  allows 
the  edge  of  the  lung  to  come  down  mto  the  chink  between  the  dia- 
phragm and  thorax.  This  "  peeling  oif  "  of  the  diaj^hragm  and  the 
descent  of  the  lung  during  inspiration  give  rise  to  the  moving 
shadow  above  described. 

By  thus  obser%'ing  the  excursion  of  the  diaphragm  we  can  obtain 
a  good  deal  of  information  of  clinical  value. 


INSPECTION. 


25 


In  pneumonia  of  tlie  lower  lobe,  pleuritic  effusion,  extensive  pleu- 
ritic adhesions,  or  in  advanced  cases  of  emphysema,  the  shadow  is 
absent.  This  is  explained  by  the  fact  that  in  pneumonia,  pleuritic 
effusion,  and  emphysema  the  diaphragm  is  held  off  from  the  chest 
wall  so  that  its  movements  commmiicate  no  shadow.  In  pleuritic 
adliesions  the  movements  of  the  diaphragm  are  prevented.  In 
early  phthisis  I  have  generally  found  the  excursion  of  the  dia- 
phragm diminished  upon  the  affected  side,  owing  to  a  loss  of 
elasticity  in  the  affected  lung  and  in  part  probably  to  pleuritic 
adhesions.  On  the  other  hand,  fluid  or  solid  tumors  below  the  dia- 
phragm, unless  very  large,  do  not  prevent  the  descent  of  that  muscle, 
and  so  do  not  abolish  the  diaphragm  shadow.  In  cases  in  which 
the  diagnosis  is  in  doubt  between  fluid  in  the  right  pleural  cavity 
and  an  enlargement  of  the  liver  upward  or  a  subdiaphragmatic  ab- 
seess,  the  preservation  of  the  Litten's  phenomenon  in  the  latter  two 
affections  may  be  of  great  value  in  diagnosis.  Very  large  accumu- 
lations of  ascitic  fluid  may  so  far  restrain  the  diaphragmatic  move- 
ments that  no  shadow  can  be  seen.  Great  muscular  weakness  or 
debility  may  greatly  duuinish,  but  rarely  if  ever  prevent,  the  excur- 


FiG.  25.— Excursion  of  the  Diaphragm  durtng  Forced  Respiration.     R,  Ribs ;    E,  position  of 
the  diaphragm  at  end  of  expiration ;  J,  position  of  diaphragm  at  end  of  Inspiration. 


sion  of  the  shadow.  In  persons  who  cannot  be  made  to  breathe 
deeply  enough  to  bring  it  out,  a  hard  cough  will  frequently  render 
it  visible. 

The  use  of  this  method  of  examination  tends,  to  a  certain  ex- 
tent, to  free  us  from  the  necessity  of  using  the  a;-rays,  inasmuch  as 


J^ 


26       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

it  furnishes  us  with  the  means  of  observing  the  diaphragmatic 
movements,  on  the  importance  of  which  so  much  stress  has  been 
laid  by  F.  H.  Williams  and  others,  much  more  easily  and  cheaply 
than  with  the  ic-rays,  and  upon  the  left  side,  more  plainly  as  well. 

It  also  frees  us  to  a  considerable  extent  from  the  need  of  using 
the  spirometer  to  determine  the  capacity  of  the  lungs. 

By  measuring  the  excursion  of  the  phrenic  shadow  and  taking 
account  of  the  thoracic  movement,  we  obtain  a  very  fair  idea  of  the 
respiratory  capacity  of  the  individual. 


t^ 


VII.   Observation  of  the  Cardiac  ^Movements. 


(1)  The  y^onmil  Cardiac  Imjmlse. 

With  each  systole  of  the  heart  there  may  be  seen  in  the  great 
majority  of  normal  chests  an  outward  movement  of  a  small  portion 
of  the  chest  wall  just  inside  and  below  the  left  nipple.  This  phe- 
nomenon is  known  as  the  cardiac  impulse.'  It  is  now  generally 
admitted  that  the  "  apex  impulse  "  is  caused  by  the  impact  of  a 
portion  of  the  right  ventricle  against  the  chest  wall  and  not  by  the 
apex  of  the  heart  itself.  [The  bearings  of  this  fact,  which  have 
not,  I  think,  been  generally  appreciated,  will  be  discussed  pres- 
ently.] The  position  of  the  maximum  impulse  in  adults  is  usually 
in  the  fifth  intercostal  space  just  inside  the  nipple  line.  In  chil- 
dren under  the  age  of  six  it  is  often  in  the  fourth  interspace  or 
behind  the  fifth  rib ;  while  in  persons  of  advanced  age  it  often  de- 
scends as  low  as  the  sixth  interspace.  In  adults  it  is  occasionally 
absent  even  in  perfect  health  and  under  certain  pathological  condi- 
tions to  be  later  mentioned. 

(a)  The  position  of  the  impulse  varies  to  a  certain  extent  ac- 
cordmg  to  the  position  of  the  body.  If  the  patient  lies  upon  the 
left  side,  the  heart's  apex  swings  out  toward  the  axilla,  so  that 
the  visible  impulse  shifts  from  one  to  two  and  one-half  inches  to 
the  left  (see  Fig.  26).  A  slight  shift  to  the  right  can  also  be 
brought  about  by  lying  upon  the  right  side,  and,  as  a  rule,  the  im- 

'  For  a  more  detailed  description  of  the  normal  position  of  the  cardiac 
impulse,  see  next  page. 


IXSPECTIO^\ 


27 


pulse  is.  less  visible  in  the  recumbent  than  in  the  iipright  position. 
Since  the  heart  is  lifted  with  each  expiration  by  the  rise  of  the  dia- 
phragm and  falls  during  inspiration,  a  corresponding  change  can  be 
observed  in  the  apex  beat,  which,  in  forced  breathing,  may  shift  as 
much  as  one  interspace.  Of  the  changes  in  the  position  of  the  im- 
pulse brought  about  by  disease,  I  shall  speak  in  a  later  paragraph. 


Fig.  3B.— Showing  Amount  of  Shifting  of  the  Apex  Impulse  with  Change  of  Position.  The  In- 
ner dot  represents  the  position  of  the  impulse  when  the  patient  lies  on  his  back ;  the  outer 
dot  corresponds  to  the  position  of  the  apex  with  patient  on  left  side. 


(b)  Relation  of  the  maximum  cardiac  imjndse  to  the  apnx  of  the 
heart. — I  mentioned  above  that  the  maximum  cardiac  impulse  is  not 
due  to  the  striking  of  the  apex  of  the  heart  against  the  chest  wall, 
but  to  the  impact  of  a  portion  of  the  right  ventricle.  The  x)ractical 
importance  of  this  fact  is  this:  When  we  are  trying  to  localize  the 


28       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

apex  of  the  heart  in  order  to  determine  how  far  the  organ  extends 
to  the  left  and  downward,  it  will  not  do  to  be  guided  by  the  posi- 
tion of  the  viaximuvi  impulse,  for  the  apex  of  the  heart  is  almost 
always  to  be  found  three-fourths  of  an  uich  or  more  farther  to  the 
left  (see  Fig.  27).     This  may  be  proved  by  percussion  {vide  infra, 


Fig.  27,— The  Inner  Dot  is  the  Maximum  Cardiac  Impulse.    That  to  the  rig-ht  is  the  true  apex 
of  the  heart,  as  obtained  by  percussion.    The  ribs  are  numbered. 


p.  58).  The  true  position  of  the  cardiac  apex  thus  determined  cor- 
responds usually  not  with  the  maximum  impulse,  but  with  the  point 
farthest  out  and  farthest  down  at  which  any  rise  ami  fall  syn- 
chronous with  the  heart  beat  can  he  felt  (for  further  discussion  of 
this  point  see  below,  p.  213). 

(c)   Besides  the  definite  and  localized  impulse  which  has  just 


INSPECTION.  29 

been  described,  it  is  often  possible  to  see  that  a  considerable  section 
of  the  chest  wall  in  the  precordial  region  is  lifted  "e/i  masse." 
The  phenomenon  is  the  "  Herzenstoss  "  of  the  Germans,  with  which 
the  '•  Spitzenstoss "  or  cq^ex  impulse  is  contrasted.  A  variable 
amount  of  "  Herzenstoss "  can  be  seen  and  felt  over  any  normal 
heart  when  it  is  acting  rapidly  and  forcibly,  and  in  thin,  nervous 
subjects  or  in  children  even  when  the  heart  is  beating  quietly.  It 
is  more  marked  in  cardiac  neuroses  or  in  cases  in  which  the  heart 
is  hypertrophied  and  in  which  there  is  more  or  less  stiffening  of  the 
ribs  with  loss  of  their  natural  elasticity.  At  times  it  may  be 
impossible  to  localize  any  one  point  to  which  we  can  give  the 
name  of  apex  impulse,  and  what  we  see  is  the  rhythmical  rise  and 
fall  of  a  section  of  the  chest  as  large  as  the  palm  of  the  hand  or 
larger. 

(d)  Character  of  the  cardiac  impulse. — Palpation  is  considerably 
more  effective  than  inspection  in  givmg  us  information  as  to  the  na- 
ture of  the  cardiac  movements  which  giv^e  rise  to  the  "apex  beat," 
but  even  inspection  sometimes  suffices  to  show  that  the  impulse  has 
a  heaving  character  or  is  of  the  nature  of  a  short  tap,  a  peristaltic 
wave,  or  a  diffuse  slap  against  the  chest  wall.  In  some  cases  a  dis- 
tinct undulation  can  be  seen  passing  from  the  apex  region  upward 
toward  the  base  of  the  heart,  or  less  often  in  the  opposite  direction. 

(2.)  Displacement  of  the   Cardiac  Impulse. 

To  one  familiar  with  the  position,  extent,  and  character  of  the 
normal  cardiac  impulse,  any  displacement  of  this  impulse  from  its 
normal  site  or  any  superadded  pulsation  in  another  part  of  the  chest 
is  apparent  at  a  glance.  I  will  consider  first  the  commonest  forms 
of  dislocation  of  the  apex  impulse. 

(a)  Displacement  of  the  cardiac  impulse  due  to  h]jpertrop)hy  and 
dilatation  of  the  heart. — By  far  the  most  common  directions  of  dis- 
placement are  toward  the  left  axilla,  or  downward.  As  a  rule,  it 
is  displaced  in  both  these  directions  at  once.  I  shall  return  to  this 
subject  more  in  detail  under  the  heading  Cardiac  Hypertrophy,  but 
here  I  may  say  that  enlargements  of  the  left  ventricle  tend  espe- 
cially to  displace  the  apex  impulse  downward,  while  enlargements  of 


30       PHYSICAL  DIAGNOSIS   OF  DISEASES   OF  THE  CHEST. 

the  right  ventricle  are  more  commonly  associated  with  displacement 
of  the  impulse  toward  the  axilla. 

(^>)  Next  to  hypertrophy  and  dilatation  of  the  heart  perhaps  the 
commonest  cause  of  dislocation  of  the  cardiac  impulse  is  pressure 
from  below  the  diaphragm.  "When  the  diaphragm  is  raised  by  a 
large  accumulation  of  gas  or  fluid  or  by  solid  tumors  of  large  size, 
we  may  see  the  apex  beat  in  the  fourth  interspace  and  often  an  inch 
or  more  inside  the  nipi:»le  Ime. 

(c)  Of  nearly  equal  frequency  is  displacement  of  the  heart  due 
to  jyleuri fie  effusion  or  to  pneumothorax. 

^Mien  a  considerable  amount  of  air  or  fluid  accumulates  in  the 
left  pleural  cavity,  the  apex  of  the  heart  is  displaced  to  the  right 
so  that  it  may  be  concealed  behind  the  sternum  or  be  visible  beyond 
it  to  the  right ;  in  extreme  cases  it  may  be  dislocated  as  far  as  the 
right  nipple.  Eight  pleuritic  effusions  have  far  less  effect  upon 
the  position  of  the  cardiac  impulse,  but  when  a  very  large  amount 
of  fluid  accumulates  we  may  see  the  impulse  displaced  considerably 
toward  the  left  axilla. 

(</)  I  have  mentioned  causes  tending  to  push  the  heart  to  the 
right,  to  the  left,  or  nptcard.  Occasionally  the  heart  is  pushed 
(Imnmvard  by  an  aneurismal  tumor  or  a  neoplasm  of  the  mediasti- 
num. In  these  cases  there  is  usually  more  or  less  displacement  to 
the  left  as  well.  In  old  age  the  aorta  sags  or  stretches  a  little, 
p.nd  hence  the  apex  beat  may  descend  to  the  sixth  interspace.  A 
similar  stretching  of  the  aorta  may  be  produced  by  the  weight  of 
a  hypertrophied  heart 

(e)  Displacement  of  the  cardiac  impulse  resulting  from  adhesions 
of  the  pericardium,  or  of  the  pleura,  with  subsequent  contraction, 
occurs  \\\  fibroid  jthtJiisis  and  in  some  cases  of  long-standing  disease 
of  the  pleura.  Through  the  effect  of  negative  pressure  the  heart 
may  be  sucked  into  the  space  formerly  occupied  by  a  portion  of  the 
lung,  when  the  latter  has  become  contracted  by  disease.  It  seems 
likely,  however,  that  in  the  majority  of  cases  adhesions  between 
the  pleura  and  pericardium  play  a  part  in  such  displacement.  By 
these  means  the  heart  may  be  displaced  to  the  right  of  the  sternum, 
as  it  is  by  left-sided  pleuritic  effusion.     It  is  often  drawn  upward 


INSPECTION.  31 

as  well  as  to  the  right  in  such  cases  by  the  contraction  which  takes 
l>lace  in  the  upper  part  of  the  lung.  JNIore  rarely  we  may  see  the 
heart  drawn  toward  the  left  clavicle  in  fibroid  phthisis  of  the  left 
apex. 

(/")  Distortion  of  the  thorax  due  to  spinal  curvature  or  other 
causes  may  bring  about  a  considerable  displacement  of  the  heart 
from  its  normal  position. 

((/)  Dextrocardia  and  Situs  Inversus. — In  rare  cases  a  displace- 
ment of  the  apex  impulse  to  the  right  of  the  sternum  may  be  due 
either  to  a  transjwsition  of  all  viscera  [the  liver  being  found  upon 
the  left,  the  spleen  upon  the  right,  etc.],  or  to  dextrocardia,  in  which 
the  heart  alone  is  transposed  while  the  other  viscera  retain  their 
normal  places  (see  Fig.  138,  p.  302). 

Snmviarij. 

The  apex  impulse  is  displaced  by 

((/)  Hyi^ertrophy  and  dilatation  of  the  heart. 

(J))  Pressure  from  below  the  diaphragm. 

(c)  Air  or  fluid  in  one  pleural  cavity,  especially  the  left. 

(d)  Aneurism,  mediastinal  growths,  and  sagging  of  the  aorta. 

(e)  Fibroid  phthisis. 
(/)  Spinal  curvature. 

(ff)  Transposition  of  the  heart  or  of  all  the  viscera. 

(3)  Apex  Retraction. 

Before  leaving  the  subject  of  the  cardiac  impulse  it  seems  best 
to  speak  of  those  cases  in  which  during  systole  we  see  a  retraction 
of  one  or  more  interspaces  at  or  near  the  point  where  the  cardiac 
impulse  normally  appears. 

(«)  In  by  far  the  greater  number  of  instances  such  retraction  is 
due  to  negative  pressure  produced  within  the  chest  by  the  vigorous 
contraction  of  a  more  or  less  hypertrophied  and  dilated  heart.  In 
these  cases  the  retraction  is  usually  to  be  seen  in  several  inter- 
spaces. Such  retraction  is  not  at  all  uncommon  and  usually  at- 
tracts no  attention. 

{h)  In  rarer  cases  several  interspaces,  both  in  the  precordial 


32       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

region  and  in  the  left  loAver  axilla  and  back,  may  be  drawn  in  as 
a  result  of  adhesions  between  the  pericardium  and  the  chest  wall, 
such  as  form  in  cases  of  adherent  pericardium  and  fibrous  medias- 
tinitis  (see  below,  pages  216  and  295). 

(4)  J^j^ihja style  Pidsatloii. 

In  a  considerable  portion  of  healthy  adults  a  pulsation  at  the 
epigastriiim  synchronous  with  the  systole  of  the  heart  is  to  be  seen 
from  time  to  time.  Such  pulsation  has  often  been  treated  as  evi- 
dence of  hypertrophy  of  the  right  ventricle  of  the  heart,  but  this  I 
believe  to  be  an  error.  It  is  not  at  all  uncommon  to  find,  post  mor- 
tem, considerable  hypertrophy  of  the  right  ventricle  in  cases  in 
Avhich  during  life  no  epigastric  pulsation  has  been  visible,  while,  on 
the  other  hand,  the  heart  is  frequently  found  normal  at  autopsy  in 
cases  in  A'hich  during  life  there  has  been  marked  epigastric  pulsa- 
tion. In  some  cases  such  pulsation  is  to  be  explained  as  the  trans- 
mission of  the  heart's  impulse  through  the  liver,  or  as  a  lifting  of 
that  organ  by  the  movements  of  the  abdominal  aorta.  In  other 
cases  it  is  more  difficult  to  explain. 

(5)    Visible  Pulsations  due  to    Uucoverinrj  of  Portions  of  the  Heart 
XormuUy  Covered  hy  the  Lungs. 

One  of  the  commonest  causes  of  visible  pulsations  in  i)arts  of 
the  chest  where  normally  none  is  to  be  seen  is  retraction  of  the 
lung. 

(it)  It  is  in  chlorosis,  perhaps,  that  we  most  frequently  see 
such  pulsations.  In  that  disease,  as  in  other  debilitated  states,  the 
lungs  are  often  not  adequately  expanded  owing  to  the  superficiality 
of  the  respiration,  and  accordingly  their  margms  do  not  cover  as 
much  of  the  surface  of  the  heart  as  they  do  in  healthy  adults. 
This  results  in  rendering  visible,  in  the  second,  third,  or  fourth  left 
interspace  near  the  sternum,  pulsations  transmitted  from  the  conns 
arteriosus  or  from  the  right  ventricle.  Less  commonly,  similar  pul- 
sations may  be  seen  on  the  right  side  of  the  sternum. 

{b)  A  rarer  cause  of  retraction  of  the  lungs  is  fibroid  phthisis 
or  chronic  interstitial  pneumonia.     In  these  diseases  a  very  large 


INSPECTION. 


33 


area  of  pulsation  may  be  seen  in  the  precordial  region  owing  to  the 
entire  uncovering  of  the  heart  by  the  retracted  lung,  even  when  the 
heart  is  not  drawn  out  of  its  normal  position. 

YIII.  Aneurism  axd  Other   Causes   of   Abnormal   Thoracic 

Pulsation. 

So  far  I  have  spoken  altogether  of  pulsations  transmitted  di- 
rectly to  the  thorax  by  the  heart  itself,  but  we  have  also  to  bear  in 


Fig.  :ft<.— Position  Wlien  Loolving  for  Slight  Aneurismal  Pulsation. 

mind  that  a  dilated  aorta  may  transmit  to  the  chest  wall  pulsations 
which  it  is  exceedingly  important  for  us  to  recognize  and  properly  to 
interpret.  Ko  disease  is  easier  to  recognize  than  aneurism  when  the 
growth  has  perforated  the  chest  wall  and  appears  as  a  tumor  exter- 
nally, but  it  is  much  more  important  as  well  as  much  more  difficult 
to  recognize  the  disease  while  it  is  confined  within  the  thorax.  In 
such  cases,  the  movements  transmitted  from  the  aorta  to  the  chest 
wall  may  be  so  slight  that  only  the  keenest  and  most  thorough  in- 
spection controlled  by  palpation  will  detect  them.  When  slight 
pulsations  are  searched  for,  the  patient  should  be  put  in  a  position 
3 


34       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

shown  in  Fig.  28,  and  the  observer  shoiikl  place  himself  so  that  his 
eye  is  as  nearly  as  possible  on  a  level  with  the  chest  and  looks 
across  it  so  that  he  sees  it  m  proiile.  In  this  position  he  can  make 
out  pulsations  which  are  totally  invisible  if  the  patient  sits  facing 
the  light. 

Pulsations  due  to  aneurism  are  most  apt  to  be  seen  in  the  first 
or  second  right  interspace  near  the  sternum,  and  not  infrequently 
the  clavicle  and  the  adjacent  parts  may  be  seen  to  rise  slightly  with 
every  beat  of  the  heart,  but  in  any  part  of  the  chest  wall  pulsa- 
tions due  to  an  aneurism  are  occasionally  to  be  seen,  and  should  be 
looked  for  scrupulously  Avhenever  the  symptoms  of  the  case  suggest 
the  possibility  of  this  disease  (see  below,  p.  221). 

PnlsaHnfjf  Pleurisy. 

In  cases  of  purulent  pleurisy  in  which  the  pus  has  worked  its 
way  out  betwen  the  ribs  so  that  it  is  covered  only  by  the  skm  and 
subcutaneous  tissues,  a  pulsation  transmitted  from  the  heart  may 
become  visible,  and  the  resemblance  to  the  pulsation  seen  in  aneu- 
rism may  be  confusing.  Such  pulsation  is  apt  to  be  seen  in  the 
upper  and  front  portions  of  the  chest.  Very  rarely  a  pleuritic  effu- 
sion which  has  not  burrowed  into  the  chest  wall  may  transmit  to 
the  latter  a  Ava^^y  movement  corresponding  to  the  motions  set  up 
in  the  fluid  by  the  cardiac  contractions. 

IX.    IXSPECTIOX    OF    THE    PERIPHERAL    VESSELS. 

In  a  work  dealing  with  diseases  of  the  heart  and  lungs  it  is  im- 
possible to  avoid  reference  to  vascular  phenomena  apparent  in  the 
neck  or  in  the  extremities,  since  such  phenomena  have  a  very  direct 
bearing  upon  the  interpretation  of  the  conditions  obtaining  within 
the  chest.  Inspection  plays  a  very  large  part  in  the  study  of  these 
vascular  phenomena.     We  should  look  for : 

(a)  Venous  phenomena. 

(b)  Arterial  phenomena. 

(c)  Capillary  phenomena. 


INSPECTION.  35 


[a)  Ins^yection  of  the  Vems. 

1.  The  condition  of  the  veins  of  the  neck  is  of  considerable  im- 
portance in  the  diagnosis  of  diseases  of  the  heart  and  lungs.  Where 
the  tissues  of  the  neck  are  more  or  less  wasted  the  veins  may  be 
quite  prominent  even  when  no  disease  exists  within  the  chest,  and 
in  such  cases  they  may  be  more  or  less  distended  during  each  expi- 
ration, especially  if  dyspnoea  or  cough  is  present.  If  the  veins 
are  completely  emptied  during  each  expiration  and  on  both  sides  of 
the  neck,  we  can  usually  infer  that  there  is  an  overdistention  of  the 
right  side  of  the  heart.  \Yhen  a  similar  phenomenon  occurs  on 
one  side  only,  it  may  mean  pressure  upon  one  innominate  vein.  So 
far  I  have  spoken  of  venous  changes  synchronous  with  respiration, 
but  we  may  have  also 

2.  A  jjvesi/stolic  pulsation  or  nndulation  seen  either  in  the  ex- 
ternal jugular  vein  or  in  the  bulbus  jugularis  between  the  two 
attachments  of  the  sternomastoid  muscles.  Such  pulsation  or 
undulation,  which  is  to  be  seen  just  before  each  systole  of  the 
heart,  is  not  necessarily  anything  abnormal  and  must  be  carefully 
distinguished  from 

3.  Sijstolic  venous  jndsatio?!,  such  as  occurs  in  one  of  the  most 
serious  valvular  diseases  of  the  heart — tricuspid  regurgitation.' 
Systolic  venous  pulsation  is  more  often  seen  upon  the  right  side 
than  upon  the  left  side  of  the  neck.  There  may  be  a  wave  during 
the  systole  of  the  auricle  and  another  during  the  systole  of  the  ven- 
tricle, the  latter  closely  following  the  former.  In  any  case  in 
Avhich  a  doubt  arises  whether  a  pulsation  in  the  veins  of  the  neck 
is  due  to  tricuspid  regurgitation,  it  is  well  to  try  the  experiment  of 
emptying  the  vein  by  stroking  it  from  below  upward.  If  it  imme- 
diately fills  from  below,  we  may  be  practically  certain  that  tricus- 
pid regurgitation  is  present.  In  the  vast  majority  of  cases  of  ve- 
nous pulsation  due  to  other  causes  or  occurring  in  healthy  persons 

'  A  pulsating  carotid  may  transmit  an  up-and-down  motion  to  the  veins 
overlying  it.  In  such  cases,  if  the  veins  be  emptied  by  "milking"  them  up- 
ward, they  will  not  refill  from  below. 


36       PHYSICAL  DIAGNOSIS  OF  DISEASES   OF  THE  CHEST. 

a  vein  will  not  refill  from  below  if  emptied  in  the  manner  above 
described. 

4.  Rarely,  superficial  veins  may  be  seen  to  pulsate  in  other  parts 
of  the  body,  especially  in  aortic  regurgitation,  and  occasionally 
large  and  tortuous  veins  may  be  seen  pulsating  upon  the  chest  wall, 


Fig.  29.— Tortuous  Veins  on  Chest  and  Abdomen. 

representing  an  attempt  at  collateral  circulation  when  one  or  the 
other  vena  cava  is  compressed  (Fig.  29). 

(/v)  Arterial  Phenomena. 

1.  In  thin  or  nervous  persons  pulsations  are  not  infrequently  to 
be  seen  in  the  carotids  independent  of  any  abnormal  condition  of 
the  heart. 

2.  Very  violent  throbbing  of  the  carotids,  more  noticeable  than 


INSPECTION 


37 


that  seen  in  health,  occurs  in  many  cases  of  aortic  regurgitation 
and  occasionally  in  simple  hypertrophy  of  the  heart  without  any 
valvular  disease.  From  the  same  causes,  visible  pulsation  may 
occur  in  the  subclavian,  axillary,  brachial,  and  radial  arteries,  as 
well  as  in  the  large  arterial  trunks  of  the  lower  extremity. 

I  lately  examined  a  blacksmith  whose  heart  was  considerably 
enlarged  by  hard  work,  but  without  any  valvular  disease.     Pulsa- 


FiG.  30.— Enlarged  Tortuous  Brachial  Arteries  (Arterio-sclerosis). 

tion  was  violent  in  all  the  peripheral  arteries  which  I  have  just 
named. 

3.  In  arterio-sclerosis  occurring  in  spare,  elderly  men,  with  or 
without  aortic  regurgitation,  one  often  notices  a  lateral  excursion  of 
the  tortuous  brachial  arteries  synchronous  with  every  heart  beat. 
An  up-and-down  pulsation  may  occur  at  the  same  time.  Not  infre- 
quently the  arteries  which  are  stiffened  by  deposition  of  lime  salts 
(see  below,  page  55)  stand  out  visibly  as  enlarged,  tortuous  cords 
upon  the  temple  and  along  the  inner  side  of  the  biceps  muscle, 
(see  Figs.  30  and  31)  and  occasionally  the  course  of  the  radial  artery 


38       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

maybe  traced  over  a  considerable  distance  in  the  forearm.  In  rare 
cases  inequalities  produced  in  tlie  arterial  wall  by  deposition  of 
lime  salts  may  be  visible  as  Avell  as  palpable. 

(c)  Cajiillary  Pulsation. 

If  a  microscopic  slide  is  placed  against  the  mucous  membrane  of 
the  lower  lip  so  as  partially  to  blanch  its  surface,  one  may  see,  with 


Fig.  31.— Enlarged  and  Tortuoiis  Brachial  Artery  (Arterio-sclerosis). 

each  beat  of  the  heart  (in  cases  of  aortic  regurgitation  and  sometimes 
in  other  conditions),  a  delicate  flushing  of  the  blanched  surface  be- 
neath the  glass  slide.  The  same  pulsation  is  sometimes  to  be  ob- 
served imder  the  finger  nails,  or  may  be  still  better  brought  oiit  by 
drawing  a  pencil  or  other  hard  substance  across  the  forehead  so  as 
to  cause  a  line  of  hyperaemia,  at  the  edge  of  which  the  systolic  flush- 
ing occurs.  This  phenomenon  will  be  referred  to  again  when  we 
come  to  speak  of  aortic  regurgitation.  Here  it  suffices  to  say  that 
it  is  not  in  any  way  peculiar  to  that  disease,  and  occurs  occasion- 


INSPECTION.  39 

ally  iu  health  or  in  conditions  associated  with  low  tension  in  the 
peripheral  arteries,  as  well  as  in  any  area  of  inflammatory  hyper- 
semia  (jumping  toothache,  throbbing  felon,  etc.). 

X.     IXSPECTIOX    OF    THE    SkIX    AXD     MuCOUS    MeMBRAXES. 

Light  may  be  thrown  upon  the  diagnosis  of  diseases  of  the  chest 
by  observing  the  color  and  condition  of  the  cutaneous  surfaces  as 
well  as  of  the  mucous  membranes.  AVe  should  look  for  the  follow- 
ing conditions : 

(1)  Cyanosis. 

(2)  (Edema. 

(3)  Pallor. 
^(4)  Jaundice. 

(o)   Scars  and  eruptions. 

(1)    Cijanosis. 

By  cyanosis  we  mean  a  purplish  or  grayish-blue  tint  notice- 
able especially  in  the  face,  in  the  lips,  and  under  the  nails.  There 
are  many  degrees  of  cyanosis,  from  the  slight  purplish  tinge  of  the 
lips,  which  a  little  overexertion  or  slight  exposure  to  cold  may  bring 
out,  lip  to  the  gray-blue  color  seen  in  advanced  cases  of  pulmonary  or 
cardiac  disease,  or  the  dark  reddish-blue  seen  ia  congenital  malfor- 
mations of  the  heart.  Cyanosis  makes  a  very  different  impression 
iipon  \is  when  it  is  combined  with  pallor  on  the  one  hand  or  with 
jaundice  on  the  other.  When  combined  with  pallor,  one  gets  vari- 
ous ashy-gray  tints,  while  the  admixture  of  cyanosis  and  jaundice 
results  in  a  color  very  difficult  to  describe,  sometimes  approaching 
a  greenish  hue.     The  commonest  causes  of  cyanosis  are : 

(a)  Valvular  or  parietal  disease  of  the  heart. 

(h)  Emphysema. 

(c)  Asthma. 

{d)  Pneumonia. 

\e)  Phthisis. 

(/)  In  some  persons  a  certain  degree  of  cyanosis  of  the  lips 
exists  despite  perfect  health.  This  is  especially  true  of  weather- 
beaten  faces  and  those  of  the  so-called  "full-blooded"  type. 


40       PHYSICAL  DIAGXOSIS  OF  DISEASES  OF  THE  CHEST. 

A  rare  but  very  striking  type  of  cyanosis  is  that  seen  in  cases 
of  congenital  heart  disease,  in  which  the  lips  may  be  indigo  blue 
in  color  or  almost  black  while  yet  no  dyspnoea  is  present. 

(2)  (Edema. 

CEdema,  or  the  accumulation  of  serous  fluid  in  the  subcutaneous 
spaces,  is  usually  appreciated  by  palpation  rather  than  by  inspec- 
tion, but  sometimes  makes  the  face  look  very  puffy,  esiiecially 
imder  the  eyes  This  is  not  a  common  occurrence  in  diseases  of 
the  chest,  in  connection  with  which  such  oedema  as  takes  place  is 
usually  to  be  found  in  the  lower  extremities  and  is  appreciable 
rather  by  palpation  than  by  inspection.  If  we  ai-e  not  familiar  with 
a  patient's  face,  we  often  do  not  perceive  in  it  the  changes  of  out- 
line due  to  oedema  which  a  friend  would  notice  at  once.  Clothing 
is  apt  to  leave  grooves  and  marks  wherever  it  presses  tightly  upon 
the  oedematous  tissues,  as  around  the  waist  or  over  the  shoulders. 
In  the  legs,  the  presence  of  oedema  may  be  suggested  by  an  unnatu- 
rally smooth,  glossy  appearance  of  the  skin  Such  impressions, 
however,  may  be  false  unless  controlled  by  palpation,  for  simple 
obesity  may  produce  very  similar  appearances. 

(3)  Pallor. 

Pallor  suggests,  though  it  does  not  in  any  way  prove,  anaemia, 
and  anaemia  is  a  characteristic  of  the  commonest  of  all  diseases  of 
the  chest — phthisis.  It  is  also  seen  in  certain  varieties  of  cardiac 
disease.  Pallor  of  the  mucous  membranes,  as  seen  in  the  lips  and 
conjunctivae,  is  much  more  apt  to  be  a  sign  of  real  ansemia  than  is 
pallor  of  the  skin.  At  best,  pallor  is  only  a  sign  which  suggests  to 
us  to  look  further  into  the  case  in  one  or  another  direction^  and  of 
itself  proves  nothing  of  importance. 

(4)  Jaundice. 

The  yellowish  tint  which  appears  in  the  skin,  and  especially  in 
the  conjvmctivae,  when  the  escape  of  bile  from  the  liver  is  hindered, 
is  sometimes  to  be  seen  in  connection  with  uncompensated  heart 


INSPECTION.  41 

disease  when  the  liver  is  greatly  distended  by  passive  congestion 
Pneumonia  is  occasionally  complicated  by  jaundice;  but  beyond 
this  I  know  of  no  special  connection  between  this  symptom  and 
diseases  of  the  chest. 

(5)  Scars  and  Eimptions. 

In  cases  of  suspected  syphilis  of  the  lung  or  bronchi  the  pres- 
ence of  scars  and  eruptions  suggestive  of  syphilis  may  be  useful  in 
diagnosis. 

XI.  Enlarged  Glands. 

Koutine  inspection  of  the  chest  may  reveal  the  presence  of  en- 
larged glands  in  the  neck  or  axillae,  and  may  thereby  give  us  a  clew 
to  the  nature  of  some  intrathoracic  disease ;  for  example,  the  pres- 
ence of  enlarged  glands  in  the  neck,  especially  if  there  are  any 
scars,  sinuses,  or  other  evidence  that  suppuration  is  going  on  or 
has  formerly  taken  place  in  them,  suggests  the  possibility  of  pul- 
monary tuberculosis  or  of  an  enlargement  of  the  bronchial  and  me- 
diastinal glands.  Again,  malignant  disease  of  the  chest  is  some- 
times associated  with  the  metastatic  nodules  over  the  clavicle,  and 
a  microscopic  examination  of  them  may  thus  reveal  the  nature  of 
the  intrathoracic  disease  to  which  they  are  secondary.  Very  large 
and  matted  masses  of  glands  above  the  clavicle,  which  have  never 
suppurated  and  have  been  painless  and  slow  in  their  growth,  sug- 
gest the  presence  of  similar  deposits  in  the  mediastmum  as  a  part 
of  the  symptom  complex  known  as  "Hodgkin's  disease."  The 
presence  of  a  goitre  or  enlargement  of  the  thyroid  gland  may  ac- 
count for  a  well-marked  dyspnoea. 

Syphilis  produces  general  glandular  enlargement ;  the  posterior 
cervical  and  the  epitrochlear  glands  are  often  involved,  but  this  is 
also  the  case  in  many  diseases  other  than  syphilis. 


CHAPTER   11. 

PALPATION   AXD   THE   STUDY   OF   THE  PULSE. 

I    Palpation. 

The  most  important  points  to  be  determined  by  palpation — that 
is,  by  laying  the  hand  upon  the  surface  of  the  chest — are : 

(1)  The  position  and  character  of  the  apex  heat  of  the  heart. 

(2)  The  presence  of  a  "  thrill "  (see  below) . 

(3)  The  vibrations  of  the  spoken  voice  C^  tactile  f rem itus  "). 

(4)  The  presence  of  pleuritic  or  pericardial, /vv'c^ to ;i. 

Other  less  important  data  furnished  by  palpation  will  be  men- 
tioned later. 

(1)  The  A^ex  Beat. 

(a)  Jn  feeling  for  the  apex  imj)ulse  of  the  heart,  one  should 
first  lay  the  palm  of  the  hand  lightly  upon  the  chest  just  below  the 
left  nipple.  In  this  way  we  can  appreciate  a  good  deal  about  the 
movements  of  the  heart,  and  confirm  or  modify  what  we  have 
learned  by  insjiection.  One  learns,  in  the  first  place,  whether  the 
heart  beat  is  regular  or  not,  and  in  case  it  is  irregular,  whether  the 
beats  are  unequal  in  force  or  whether  some  are  skipped ;  further, 
one  gets  a  more  accurate  idea  than  can  be  obtained  through  inspec- 
tion regarding  the  character  of  the  cardiac  movements.  The  power- 
ful heaving  impulse  suggesting  a  hypertrophied  heart,  the  diffuse 
slap  often  felt  in  dilatation  of  the  right  ventricle,  the  sudden  tap 
characteristic  of  mitral  stenosis,  the  deliberate  thrust  occasionally 
met  with  in  aortic  stenosis,  may  be  thus  appreciated. 

(J)  After  this,  it  is  best  to  lay  the  tips  of  two  or  three  fingers 
over  the  point  Avhere  the  maximum  impulse  is  to  be  seen,  and  fol- 
low it  outward  and  downward  until  one  arrives  at  the  point  farthest 
to  the  left  and  farthest  down  at  which  it  is  still  possible  to  feel 


PALPATION  AND  THE  STUDY  OF  THE  PULSE.  43 

any  up-and-down  movement.  This  point  usually  corresponds  with 
the  apex  of  the  heart,  as  determined  by  percussion.  It  does  not 
correspond  with  the  maximum  cardiac  imjjulse,  but  is  often  to  be 
found  at  least  an  inch  farther  to  the  left  and  downward  (see  above, 
Fig.  27).  _ 

Sometimes  one  can  localize  by  palpation  a  cardiac  impulse 
which  is  not  visible ;  on  the  other  hand,  in  some  cases  we  can  see 
pulsations  that  Ave  cannot  feel.  Both  methods  must  be  used  in 
every  case. 

The  results  obtained  by  palpation  and  inspection  of  the  apex 
region  give  us  the  most  r'^liable  data  that  we  have  regarding  the 
size  of  the  heart.  Percussion  may  be  interfered  with  by  the  pres- 
ence of  gas  in  the  stomach,  of  fluid  or  adhesions  in  the  pleural  cav- 
ity, or  by  the  ineptness  of  the  observer,  but  it  is  almost  always  pos- 
sible with  a  little  care  to  make  out  by  a  combination  of  palpation 
and  inspection  the  position  of  the  apex  of  the  heart.  WTien  we 
can  neither  feel  it  nor  see  it,  we  may  have  to  fall  back  upon  auscul- 
tation, considering  the  apex  of  the  heart  to  be  at  or  near  the  point 
at  which  the  heart  sounds  are  heard  loudest.  When  endeavoring 
to  find  the  apex  of  the  heart,  we  must  not  forget  that  the  position 
of  the  patient  influences  considerably  the  relation  of  the  heart  to 
the  chest  walls  If  the  patient  is  leaning  toward  the  left  or  lying 
on  the  left  side,  the  apex  will  swing  out  several  centimetres  toward 
the  left  axilla. 

(2)  ''Thrills." 

When  feeling  for  the  cardiac  impulse  with  the  pahn  of  the 
hand,  we  are  in  a  good  position  to  notice  the  presence  or  absence 
of  a  very  important  physical  sign  to  which  we  give  the  name  of 
"thrill."  The  feeling  imparted  to  the  fingers  by  the  throat  of 
a  purring  cat  is  very  much  like  the  palpable  "  thrill "  over  the  pre- 
cordia  in  certain  diseases  of  the  heart  to  be  mentioned  later.  It  is 
a  vibration  of  the  chest  wall,  usually  confined  to  a  small  area  in  the 
region  of  the  apex  impulse,  but  sometimes  felt  in  the  second  right 
intercostal  space  or  elsewhere  in  the  precordial  region.  This  vibra- 
tion or  thrill  almost  always  occurs  intermittently,  i.e.,  only  during 


44       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

a  portion  of  the  cardiac  cycle.  When  felt  in  the  apex  region,  it 
usually  occurs  just  before  the  cardiac  impulse ;  this  fact  we  express 
by  calling  it  a  ''^presystolic  tJirill";  but  occasionally  we  may  feel  a 
systolic  thrill  at  the  apex — one,  that  is,  which  accompanies  the  car- 
diac impulse.  The  word  thrill  should  be  used  to  denote  only  a 
purring,  \'ibrating  sensation  communicated  to  the  fingers  by  the 
chest  wall.  It  is  incorrect  to  speak  of  a  thrill  as  if  it  were  some- 
thing audible. 

We  must  also  distinguish  a  purring  thrill  from  the  slight  shud- 
der or  jarring  which  often  accompanies  the  cardiac  impulse  in  func- 
tional neuroses  of  the  heart  or  in  conditions  of  mental  excitement. 

As  a  rule  we  can  appreciate  a  thrill  more  easily  if  we  lay  the 
fingers  very  lightly  upon  the  chest,  xising  as  little  pressure  as  pos- 
sible. Firm  pressure  may  prevent  the  occurrence  of  the  vibrations 
which  we  desire  to  investigate.  Of  the  thrills  felt  over  the  base  of 
the  heart,  more  will  be  said  in  Chapter  YII. 

(3)   Vibrations  Conivuinicated  to  the  Chest  Wall  hij  the  Voice. 

*■'  Tactile  fremitus"  is  the  name  given  to  the  sense  of  vibration 
communicated  to  the  hand  if  the  latter  is  laid  upon  the  chest  while 
the  patient  repeats  some  short  phrase  of  words.  The  classical 
method  of  testing  tactile  fremitus  is  to  ask  the  patient  to  count 
"one,  two,  three,"  or  to  repeat  the  words  "ninety -nine  "  while  the 
palm  of  the  hand  is  laid  flat  ujion  the  chest.  The  amount  of  fre- 
mitus to  be  obtained  over  a  given  part  of  the  thorax  varies,  of  course, 
according  to  the  loudness  of  the  words  spoken,  and  is  influenced 
also  by  the  vowels  contained  in  them.  A  certain  uniformity  is  ob- 
tained by  getting  the  patient  to  repeat  always  the  same  formula. 
Thus,  he  is  likely  to  use  the  same  amount  of  force  each  time  he  re- 
peats them  and  to  use  approximately  the  same  pitch  of  voice. 

Other  things  being  equal,  the  fremitus  is  greater  in  men  than 
in  women,  in  adults  than  in  children,  and  is  more  marked  in  those 
whose  voices  are  low  pitched  than  in  those  whose  voices  are  rela- 
tively shrill  The  amount  of  fremitus  also  varies  widely  in  differ- 
ent parts  of  the  healthy  chest  A  glance  at  Fig  32  will  help  us  to 
realize  this      The  parts  shaded  darkest  communicate  to  the  fingers 


PALPATION  AND  THE  STUDY  OF  THE  PULSE. 


45 


the  most  marked  fremitus,  while  in  the  pai-ts  not  shaded  at  all,  lit- 
tle or  no  fremitus  is  felt.  Intermediate  degrees  of  vibration  are 
represented  by  intermediate  tints  of  shading.  From  this  diagram 
we  see  at  once  (a)  that  the  maximum  of  fremitus  is  to  be  obtained 
over  the  apex  of  the  right  lung  in  front,  (b)  that  it  is  greater  in  the 
upper  part  of  the  chest  than  in  the  lower,  and  somewhat  greater 
throughout  the  right  chest  than  in  corresponding  parts  of  the  left. 


Fig.  32.— Distribution  of  Tactile  Fremitus. 


This  natural  inequality  of  the  two  sides  of  the  chest  cannot  he  too 
stronyli/  emphasized. 

Comparatively  little  fremitus  is  to  be  felt  over  the  scapulae  be- 
hind, and  still  less  in  the  precordial  region  in  front.  The  outlines 
of  the  limgs  can  be  quite  accurately  mapped  out  by  means  of  the 
tactile  fremitus  in  adults  of  low-pitched  voice.  In  children,  as  has 
been  already  mentioned,  fremitus  is  usually  very  slight  and  may  be 
entirely  absent,  and  in  many  women  it  is  too  slight  to  be  of  any 
considerable  diagnostic  value.  Again,  some  very  fat  persons  and 
those  with  thick  chest  walls  transmit  but  little  vibration  to  their 
chest  walls  when  they  speak.  On  the  other  hand,  in  emaciated 
patients  or  in  those  with  thin-walled,  flexible  chests,  the  amount 
of  fremitus  is  relatively  great. 


46       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 


Bearing  in  mind  all  these  disparities — disparities  both  between 
persons  of  different  age  and  diiferent  sex,  and  between  the  two 

sides  of  the  chest  in  any  one 
person — we  are  in  a  position  to 
appreciate  the  modifications  to 
which  disease  gives  rise  and 
which  ma}'  be  of  great  impor- 
tance in  diagnosis.  These  vari- 
ations are : 

(a)  Diminution  or  absence 
of  fremitus. 

(fj)  Increase  or  absence  of 
fremitus. 

(a)  If  the  lung  is  jjushed 
aAvay  from  the  chest  wall  by  the 
presence  of  air  or  fluid  in  the 
pleural  cavity,  we  get  a  diminu- 
tion or  absence  of  tactile  fremi- 
tus— diminution  Avhere  the  layer 
of  fluid  or  air  is  very  thin,  ab- 
sence where  it  is  of  considerable 
thickness. 

{!>)  Solidification  of  the  lung 
due  to  phthisis  or  pneumonia  is 
the  commonest  cause  of  an  in- 
crease in  tactile  fremitus.  Fur- 
ther details  as  to  the  variations 
in  amount  of  fremitus  in  different  diseases  may  be  found  in  later 
chapters  of  this  book. 

(4)  Friction,  Pleural  or  Pericnrdlnl. 

In  many  cases  of  inflammatory  roughening  of  the  pleural  sur- 
faces ("  dry  pleiirisy ")  a  grating  or  rubbing  of  the  two  surfaces 
upon  each  other  may  be  felt  as  well  as  heard  during  the  movements 
of  respiration,  and  especialh*  at  the  end  of  inspiration.  Such  fric- 
tion is  most  often  felt  at  the  bottom  of  the  axilla,  on  one  side  or 


Fig.  33.-Sho\ving  Point  (F)  at  Which  Pleural 
Friction  Is  Most  Often  Heard. 


PALPATION  AND  THE  STUDY  OF  THE  PULSE. 


47 


the  other,  where  the  diaphragmatic  pleura  is  in  close  apposition 
with  the  costal  layer  (see  Fig.  33,  p.  46). 

Similarly,  in  roughening  of  the  pericardial  surfaces  ("dry"  or 
"plastic"  pericarditis)  it  is  occasionally  possible  to  feel  a  grating 
or  rubbing  in  the  precordial  region  more  or  less  synchronous  with 
the  heart's  movements.  Such  friction  is  most  often  to  be  felt  in 
the  region  of  the  fourth  left  costal  cartilage  (see  Fig.  34). 

Palpable  friction  is  of  great  value  in  diagnosis  because  it  is  a 
sign  about  which  we  can  feel  no  doubt ;  as  such  it  frequently  con- 


FiG.  34.— Showing  Point  (P)  at  Which  Pericardial  Friction  is  Most  Often  Heard. 

firms  our  judgment  in  cases  in  which  the  auscultatory  signs  are  less 
clear.  Friction  sounds  heard  with  the  stethoscope  may  be  closely 
simulated  by  the  rubbing  of  the  stethoscope  upon  the  skin,  but  pal- 
pable friction  is  simulated  by  nothing  else,  unless  occasionally  by 

(5)  Palpable  Rales. 

Occasionally  coarse,  dry  rales  communicate  a  sensation  to  the 
hand  placed  upon  the  chest  in  the  region  beneath  which  the  rales 
are  produced ;  to  the  practised  hand  this  sensation  is  quite  differ- 
ent from  that  produced  by  pleural  friction,  although  the  difference 
is  hard  to  describe. 


48       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

(6)  Tender  points  upon  the  thorax. 

In  intercostal  neuralgia,  dry  pleurisy,  necrosis  of  a  rib,  and 
sometimes  in  phthisis,  one  finds  ai-eas  of  marked  tenderness  in 
different  parts  of  the  chest.  The  position  of  the  tender  points  in 
intercostal  neuralgia  generally  corresponds  Avith  the  point  of  exit 
of  the  intercostal  nerves.     These  points  are  shoAvn  in  Fig.  35. 

The  tenderness  in  phthisis  is  most  apt  to  be  in  the  upper  and 
front  portions  of  the  chest.  In  neurotic  individuals  we  sometimes 
find  a  very  superficial  tenderness  over  pai-ts  of  the  thorax ;  in  such 


Fig.  35.— Showing  Points  of  Exit  of  the  Intercostal  Nerves. 


cases  pain  is  produced  by  very  light  pressure,  but  not  by  firm  press- 
ure at  the  same  j)oint. 

(7)  The  presence  of  pulsations  in  pai'ts  of  the  chest  where  nor- 
mally there  should  be  none  is  suggested  by  inspection  and  con- 
firmed by  palpation.  It  is  not  necessary  to  repeat  what  was  said 
above  as  to  the  commonest  causes  of  such  abnormal  pulsations. 
When  searching  for  slight,  deep-seated  pulsation  (e.(/.,  from  an 
aortic  aneurism),  it  is  well  to  use  bimanual  palpation,  keeping  one 
hand  on  the  front  of  the  chest  and  the  other  over  a  corresponding 
area  in  the  back. 

(8)  Fluctuation  or  elasticity  in  any  tumor  or  projection  from 


PALPATION  AND   THE  STUDY  OF  THE  PULSE.  49 

the  chest  is  a  very  important  piece  of  information  which  palpation 
may  give  us. 

(9)  The  temperature  and  quality  of  the  skin  are  often  brought 
to  our  attention  during  palpation.  After  a  little  practice  one  can 
usually  judge  the  temperature  within  a  degree  or  two  simply  from 
the  feeling  of  the  skin.  Any  roughness  or  dryness  of  the  skin 
(myxoedema,  diabetes)  is  easily  aj)preciated  as  we  pass  the  hand  over 
the  surface  of  the  thorax  or  down  the  arms.  The  same  manipula- 
tion often  brings  to  our  attention  in  cases  of  alcoholism  an  unusu- 
ally smooth  and  satiny  quality  of  the  cutaneous  surface. 

II.   The  Pulse. 

Fifty  years  ago  the  study  of  the  pulse  furnished  the  physician 
with  most  of  the  available  evidence  regarding  the  condition  of  the 
heart.  At  present  this  is  not  the  case.  With  the  increase  of  our 
knowledge  of  the  direct  physical  examination  of  the  heart,  the 
amount  of  informatioa  furnished  exclusively  by  the  pulse  has  pro- 
portionately decreased,  until  to-day,  I  think,  it  is  a  fact  that  there 
is  but  little  to  be  learned  by  studying  the  pulse  which  could  not  be 
as  well  or  better  ascertained  by  examining  the  heart  itself. 

Nevertheless,  the  radial  pulse  is  still  an  important  factor  in 
diagnosis,  prognosis,  and  treatment,  and  will  remain  so,  because  it 
gives  us  quickly,  succinctly,  and  in  almost  every  case  a  great  deal 
of  valuable  information  which  it  would  take  more  time  and  trouble 
to  obtain  by  examining  the  heart  itself.  As  we  feel  the  pulse,  we 
get  at  once  a  fact  of  central  importance  in  the  case ;  by  the  pulse 
the  steps  of  our  subsequent  examination  are  guided.  In  emergen- 
cies or  accidents  the  pulse  gives  us  our  bearings  and  tells  us  whether 
or  not  the  patient's  condition  is  one  demanding  immediate  succor — 
e.f/.,  hypodermic  stimulation — and  whether  the  outlook  is  bright  or 
dark.  To  gather  this  same  information  by  examining  the  heart 
itself  would  involve  losing  valuable  time. 

Again,  when  one  has  to  see  a  large  number  of  patients  in  a 
short  time,  as  in  visiting  a  hospital  ward  or  on  the  crowded  days 
of  private  practice,  the  pulse  is  an  invaluable  short  cut  to  some  of 
the  most  important  data. 
4 


50       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

Moreover,  there  are  some  important  inferences  which  the  pulse 
and  onli/  the  j^uhe  enables  us  to  make.  They  are  not  numerous,  but 
their  value  may  be  great.  Delay  in  one  radial  pulse  when  taken  in 
connection  with  other  signs  may  furnish  decisive  evidence  of  aneu- 
rism of  the  aortic  arch ;  aortic  stenosis  is  a  lesion  which  cannot  be 
diagnosed  unless  the  pulse  shows  certain  characteristic  features; 
arterial  degeneration  may  betray  its  presence  chiefly  in  the  periph- 
eral arteries. 

Since,  then,  the  condition  of  the  pulse  furnishes  information  of 
crucial  importance  in  a  few  diseases,  and  is  a  quick,  reliable,  and 
convenient  indication  of  the  general  condition  of  the  circulation  in 
all  cases,  it  is  essential  that  we  should  study  it  most  carefully  both 
in  health  and  in  disease. 

How  to  Feel  the  Pulse. 

(a)  We  usually  feel  for  the  pulse  in  the  radial  artery  because 
this  is  the  most  superficial  vessel  which  is  readily  available.  Oc- 
casionally, as  when  the  Avrists  are  swathed  in  surgical  dressings  or 
tied  up  in  a  straight- jacket,  we  make  use  of  the  temporal,  facial, 
or  carotid  arteries. 

{b)  Both  radials  should  always  be  felt  at  the  same  time.  By 
making  this  a  routine  practice  many  mistakes  are  avoided  and  any 
difference  in  the  two  pulses  is  appreciated. 

(c)  The  tips  of  three  fingers  (never  the  thumb)  should  be  laid 
upon  the  artery,  and  the  following  points  noted : 

1.  The  rate  of  the  pulse. 

2.  The  rhythm  of  the  pulse  (regular  or  irregular). 

3.  The  amount  of  force  necessary  to  obliterate  it  (coynjtressi- 
hility). 

4.  The  size  and  shape  of  the  pulse  wave. 

5.  The  extent  to  which  the  artery  collapses  between  beats 
(tension) . 

6.  The  size  and  jyosition  of  the  artery. 

7.  The  condition  of  the  artery  walls. 

Each  of  these  points  will  now  be  considered  in  detail. 


PALPATION  AND   THE  STUDY  OF  THE  PULSE.  51 

1.    The  Hate  of  the  Pulse. 

In  the  adult  male  the  pulse  averages  72  to  the  minute,  in  the 
female  80.  In  children  it  is  considerably  more  frequent.  At  birth 
it  averages  about  130,  and  until  the  third  year  it  is  usually  above 
100.  In  some  families  as  low  pulse,  60  or  less,  is  hereditary ;  on  the 
other  hand,  it  is  not  very  rare  to  observe  a  permanent  pulse  rate  of 
110  or  more  in  a  normal  adult  (see  below,  p.  202).  Exercise  or  emo- 
tion quickens  the  pulse  very  markedly,  and  after  food  it  is  somewhat 
accelerated.  Some  account  of  the  causes  of  pathological  quicken- 
ing or  sloAving  of  the  pulse  will  be  found  on  pages  202  and  203. 

2.   Rhythm. 

The  pulse  may  be  irregular  in  force,  in  rhythm,  or  (as  most 
commonly  happens)  in  both  respects.  As  a  rule,  irregularities  in 
force  are  the  more  serious.  Intermitteuce  or  irregularity  in  rhythm 
alone,  means  that  the  heart  skips  one  or  more  beats  at  regular  or 
irregular  intervals.  This  may  be  a  mere  idiosyncrasy  not  associ- 
ated with  any  evidence  of  disease.  I  have  known  several  instances 
in  which  a  perfectly  sound  person  has  been  aware  of  such  an  irregu- 
larity throughout  life — the  heart  dropping  regularly  every  third  or 
fourth  beat.  Such  rhythmical  intermitteuce  in  health  is  not  un- 
common. 

AVhen  beats  are  dropped,  not  at  fixed  intervals,  but  irregularlyj 
the  i^ulse  waves  usually  vary  in  force  as  well.  This  combination 
of  irregular  cardiac  rhythm  with  variations  in  the  strength  of  the 
individual  beats  is  very  rarely  seen  in  health  and  usually  points  to 
functional  or  structural  disease  of  the  heart. 

Special  types  of  irregularity  will  be  discussed  later. 

In  general  it  may  be  said  (a)  that  irregularity  in  the  force  of 
the  pulse  beats  is  a  serious  sign,  if  overexertion  and  temporary 
toxic  influences  (tobacco,  tea,  etc.)  can  be  ruled  out;  (b)  that  it  is 
far  more  serious  when  occurring  in  connection  with  diseases  of  the 
aortic  valve  than  in  mitral  disease ;  and  (c)  that  it  often  occurs  iu 
connection  with  sclerosis  of  the  coronary  arteries  and  myocarditis. 


52       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

3.    Compressibility. 

There  is  no  single  datum  coucerning  the  pulse  more  important 
than  the  amount  of  force  needed  to  obliterate  its  beat.  We  have 
no  more  accurate  method  of  measuring  the  compressibility  of  the 
pulse  than  the  following :  Let  the  tips  of  three  fingers  rest  as  usual 
on  the  radial  artery  Then  gradually  mcrease  the  pressure  made 
upon  the  vessel  with  the  finger  nearest  the  patient's  heart  until  the 
pulse  wave  is  arrested  and  cannot  be  felt  by  the  other  fingers  which 
rest  loosely  on  the  artery.  The  degree  of  force  necessary  to  arrest 
the  wave  varies  a  great  deal  in  different  cases  and  at  different  times 
of  day,  but  by  trying  the  above  manoeuvre  day  after  day  in  as  many 
cases  as  possible  one  comes  to  possess  a  fairly  accurate  mental 
standard  or  picture  of  the  compressibility  of  the  average  pulse,  and 
is  then  able  to  estimate  in  any  given  case  whether  it  is  more  or 
less  compressible  than  usual. 

The  compressibility  of  the  pulse  is  a  rough  measure  of  the  mus- 
cular power  of  the  heart's  beat,  and  therefore  gives  us  direct  infor- 
mation about  this  important  element  in  the  patient's  condition. 

4.    The  Size  and  Shape  ofth^  Pulse  Wave. 

Of  the  use  of  the  sphygmograph  for  representing  pulse  waves  I 
shall  speak  later.  The  points  discussed  in  this  section  are  appre- 
ciable to  the  fingers. 

I.  The  size  of  the  pulse  Avave — the  height  to  which  it  lifts  the 
finger — depends  on  tAvo  factors : 

(a)  The  force  of  the  cardiac  contractions. 

(h)  The  tightness  or  looseness  of  the  ai'tery  {tension). 

If  the  arteries  are  contracted  and  small,  the  pulse  wave  corre- 
sponds, while  if  they  are  large  and  relaxed,  it  needs  only  a  moder- 
ate degree  of  power  in  the  heart  to  produce  a  high  pulse  wave.  If 
•the  tension  remains  constant  the  size  of  the  pulse  wave  depends  on 
the  force  of  the  heart's  contraction.  If  the  heart  power  remains 
.^onstant,  the  size  of  the  pulse  wave  depends  on  the  degree  of  vas- 
cular tension.  Vascular  tension  is  estunated  in  ways  to  be  de- 
scribed presently,  and  after  allowing  for  it,  we  are  enabled  to  esti- 


PALPATION  AND   THE  STUDY  OF  THE  PULSE.  53 

mate  the  power  of  the  heart's  cou tractions  from  the  height  of  the 
pulse  wave. 

II.  The  shape  of  the  indse  wave  is  also  of  importance. 

(«)  It  may  have  a  very  sharp  summit,  rising  and  falling  back 
again  suddenly;  this  is  known  as  an  ill-sustained  pulse,  and  may 
be  due  to  a  lack  of  sustained  propulsive  power  in  the  contracting 
heart  muscle,  to  low  vascular  tension,  or  to  a  combuiation  of  the 
two  causes.  A  weak  heart  when  stimulated  by  alcohol  often  pro- 
duces such  a  pulse  wave — deceptively  high  and  giving  at  first  an 
impression  of  power  in  the  heart  wall,  but  ill  sustained  and  easily 
compressible.  An  exaggeration  of  this  tyi>e  of  pulse  is  to  be  felt 
in  aortic  regurgitation  (see  Fig.  102). 

(I))  In  sharp  contrast  with  the  above  is  the  pulse  wave  which 
lifts  the  finger  gradually  and  slowly,  sustauis  it  for  a  relatively 
long  period,  and  then  sinks  gradually  down  again.  Such  a  pulse 
with  a  ''long  plateau"  instead  of  a  sharp  peak  is  to  be  felt  most 
distinctly  in  aortic  stenosis,  less  often  in  mitral  stenosis  and  other 
conditions  (see  Fig.  107). 

{c)  The  dicrotic  pulse  wave  is  one  in  which  the  secondary  wave, 
which  the  sphygmograph  shows  to  be  present  in  the  normal  pulse, 
is  much  exaggerated,  so  that  a  distinct  "  echo "  of  the  primary 
wave  is  felt  after  each  beat.  If  the  heart  is  acting  rapidly,  this 
dicrotic  wave  does  not  have  time  to  fall  before  it  is  interrupted  by 
the  primary  wave  of  the  next  beat,  and  so  appears  in  the  sphygmo- 
gi-aphic  tracing  as  a  part  of  the  up-stroke  of  the  primary  wave. 
This  is  known  as  the  *' anacrotic  pulse." 

(d)  The  shape  of  the  hif/h-tension  jmlse  tvave  will  be  described 
in  the  next  paragraph. 

5.  Tension. 

The  degree  of  contraction  of  the  vascular  muscles  determmes 
the  size  of  the  artery  and  (to  a  great  extent)  the  tension  of  tlie 
blood  within  it.  But  if  the  heart  is  acting  feebly,  there  may  be  so 
little  blood  in  the  arteries  that  even  when  tightly  contracted  they 
do  not  subject  the  blood  within  them  to  any  considerable  degree  of 
tension.     To  produce  high  tension,  then,  we  need  two  factors:  a 


54       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

certain  degree  of  power  in  the  heart  muscle,  and  contracted  arteries. 
To  produce  low  tension  we  need  only  relaxation  of  the  arteries,  and 
the  heart  may  be  either  strong  or  weak. 

The  pulse  of  low  tension  collapses  between  beats,  so  that  the  ar- 
tery is  less  palpable  than  usual  or  cannot  be  felt  at  all.     Normally, 


Fig.  36.— Sphygmographic  Tracing  of  Low  Tension  Pulse. 

the  artery  can  just  be  made  out  between  beats,  and  any  consider- 
able lowering  of  arterial  tension  makes  it  altogether  impalpable 
except  during  the  period  of  the  primary  wave  and  of  the  dicrotic 
wave,  which  is  often  very  well  marked  in  pulses  of  low  tension. 
The  shape  of  the  wave  under  these  conditions  has  already  been 
described  (see  Fig.  36). 

The  2ndse  of  hifjh  tension  is  perceptible  between  beats  as  a  dis- 
tinct cord  which  can  he  rolled  between  the  fingers,  like  one  of  the  ten- 


FiG.  37.— Sphygmographic  Tracing  of  High  Tension  Pulse. 

dons  of  the  wrist.  It  is  also  difficult  to  compress  in  most  cases,  but 
this  may  depend  rather  on  the  heart's  power  than  on  the  degree 
of  vascular  tension.  The  pulse  wave  is  usually  of  moderate  height 
or  low,  and  falls  away  slowly  Avith  little  or  no  dicrotic  wave  (see 
Fig.  37). 


PALPATION  AND   THE  STUDY  OF  THE  PULSE.  55 


6.    The  Size  and  Position  of  the  Artery. 

I  have  often  known  errors  to  occur  because  a  small  artery  is 
mistaken  for  a  Qiwall  pulse  icave.  The  size  of  the  branches  of  the 
arterial  tree  varies  a  great  deal  in  different  individuals  of  the  same 
weight  and  height,  and  if  the  radial  is  unusually  small  and  a  hur- 
ried observation  gives  vis  the  impression  (true,  so  far  as  it  goes)  that 
there  is  very  little  in  the  way  of  a  pulse  to  be  felt,  we  are  apt  to 
conclude  (wrongly,  perhaps)  that  the  heart's  work  is  not  being 
properly  performed.  The  effort  to  ol)literate  such  a  pulse,  how- 
ever, may  set  us  right  by  showing  that  despite  the  small  size  of  the 
vessel  (and  consequently  of  the  pulse  wave)  it  takes  as  much  force 
as  it  normally  does  to  obliterate  it.  Thus,  a  small  jiulse  wave  (in  a 
congenitally  small  artery)  may  be  distinguished  from  a  weak  pulse. 
From  the  contracted  artery  of  high  vascular  tension  we  distmguish 
the  congenitally  small  artery  because  the  latter  is  not  to  be  rolled 
beneath  the  fingers,  and  is  not  more  than  normally  palpable  between 
the  pulse  beats. 

Xot  infrequently  the  nurse  reports  in  alarm  that  the  patient  has 
no  pulse,  when  in  reality  the  pulse  is  excellent  but  the  artery  mis- 
placed so  as  to  be  impalpable  in  the  ordinary  situation.  It  may  be 
simply  more  deeply  set  than  normal,  so  that  the  fingers  cannot  get 
at  it,  or  it  may  run  superficially  over  the  end  of  the  radius  toward 
the  "anatomical  snuff  box."  Other  anomalies  are  less  common. 
As  a  rule,  the  other  radial  artery  is  normally  placed  and  can  be  used 
as  a  standard,  but  occasionally  both  radials  are  anomalous  and  we 
may  be  compelled  to  use  the  temporal  or  facial  instead. 

7.    The  Condition  of  the  Aiiery  Walls. 

Arterio-sclerosis  is  manifested  in  the  peripheral  arteries  in  the 
following  forms : 

[a)  Simple  stiffening  of  the  arteries  without  calcification. 

{b)    Tortuosity  of  the  arteries. 

(c)    Calcification. 

Simple  stiffening  without  calcification  is  due  to  fibrous  thicken- 


56       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

ing  of  the  intima  and  produces  a  condition  of  the  arteries  not  al- 
ways to  be  distinguished  from  high  tension.  The  artery  can  be 
rolled  under  the  fingers,  stands  out  visibly  between  the  heart's 
beats,  but  is  not  incompressible,  has  a  smooth  surface,  and  is  not 
always  tortuous.  If  it  is  tortuous  as  well  as  stiff,  we  may  con- 
clude that  there  is  endarteritis  at  any  rate,  whether  or  not  there  is 
increased  tension  as  well.  In  the  vast  majority  of  cases  the  two 
conditions  are  asssociated  and  do  not  need  to  be  distinguished. 

The  normal  radial  artery  is  straight;  hence  any  deviation  is 
evidence  of  changes  in  its  walls  and  is  easily. recognized  as  we  run 
our  fingers  up  and  down  the  vessel. 

Calcification  of  the  radial  produces  usually  a  heading  of  its  sur- 
face. As  we  move  the  fingers  along  the  artery,  quickly  and  with 
very  slight  pressure,  a  series  of  transverse  ridges  or  beads  can  be 
felt.  The  qualities  of  the  piilse  wave  within  can  usually  be  appre- 
ciated fairly  well,  in  this  type  of  artery,  but  in  very  advanced  cases 
the  calcification  is  diffuse  and  converts  the  radial  into  a  rigid  "pipe 
stem  " — absolutely  incompressible — unless  we  break  the  calcified 
coat — and  easily  mistaken  for  a  tendon.  In  such  an  artery  no 
pulse  can  be  felt. 

Such  are  the  points  to  be  observed  in  feeling  the  pulse.  To 
enumerate  the  characteristics  of  the  pulse  in  the  many  diseases  in 
which  it  affords  us  valuable  information  is  beyond  the  scope  of  this 
book.  The  qualities  to  be  expected  in  the  pulse  in  connection  with 
the  different  diseases  of  the  heart  are  described  in  the  sections  on 
those  diseases.  Here  it  will  suffice  to  enumerate  some  of  the  con- 
ditions in  which  vascular  tension  is  usually  increased  or  diminished. 

Loiv  tension  is  produced  by  moderate  exercise,  by  warmth  (e.g., 
a  warm  bath),  by  food.  Among  pathological  conditions  we  may 
mention  especially  debilitated  states,  mental  worry,  and  fever. 

High  tension  is  produced  by  cold  {e.g.,  cold  bathing,  malarial 
chills),  and  by  constipation  (in  some  cases).  As  a  rule,  the  tension 
of  the  pulse  increases  with  age  and  is  high  after  the  fiftieth  year. 
Hysteria  and  migraine  are  often  associated  with  increased  vascular 
tension.     Most  frequent  among  pathological  conditions  as  causes 


PALPATION  AND   THE  STUDY  OF  THE  PULSE.  57 

of  high  tension  are  chronic  nephritis  and  arteriosclerosis  with  the 
various  diseases  in  which  arterio-sclerosis  is  a  factor  (gout,  alcohol- 
ism, lead  poisoning,  diabetes  of  fat  old  people,  chronic  bronchitis 
with  emphysema). 

Among  valvular  heart  lesions,  aortic  and  mitral  stenosis  are  espe- 
cially apt  to  be  associated  with  increased  vascular  tension. 


-^^f  A^ 


CHAPTER  III. 

PERCUSSION 

I.  Technique. 

There  is  no  other  method  of  physical  examination  -which  needs 
so  much  practice  as  percussion,  and  none  that  is  so  seldom  thor- 
oughly learned.  Many  physicians  never  succeed  in  acquiring  a 
facility  in  the  use  of  it  sufficient  to  make  them  rely  upon  their 
results.  Undoubtedly  one  of  the  greatest  difficulties  arises  from 
the  necessity  of  being  at  once  active  and  passive — at  once  the  per- 
cussor  and  the  one  who  listens  to  the  percussion.  Students  half 
unconsciously  get  to  treat  the  percussion  as  an  end  in  itself,  and 
hammer  away  industriously  without  realizing  that  two-thirds  of  the 
attention  must  be  given  to  listening,  while  the  percussion  itself 
should  become  semi-automatic. 

It  is  undoubtedly  an  advantage  to  possess  a  musical  ear,  but  this 
is  by  no  means  a  necessity.  Some  of  the  most  accurate  percussors 
that  I  know  possess  absolutely  no  musical  ear — no  ear,  that  is,  for 
pitch — and  form  their  judgments  in  percussing  upon  the  quality  or 
intensity  of  the  note,  and  upon  the  sense  of  resistance. 

In  this  country  practically  all  percussion  is  done  with  the  fin- 
gers ;  in  Germany  instruments  are  still  used  to  a  considerable  ex- 
tent (see  Appendix). 

(a)  Mediate  and  Immediate  Percussion. 

Percussion  may  be  either  "  mediate  "  or  "  immediate, "  the  lat- 
ter term  referring  to  blows  struck  directly  upon  the  chest  with  the 
flat  of  the  hand,  or  upon  the  clavicles  with  the  tip  of  the  second 
finger. 


PERCUSSION. 


59 


(b)  Methods. 

Mediate  percussion  (which  is  used  ninety-nine  hundredths  of 
the  time)  is  performed  as  follows : 

The  patient  should  either  lie  down  or  sit  with  his  back  agamst 
some  support.     The  reason  of  this  is  that  for  good  percussion  one 


Fig 


Position  of  the  Hands  Wtieu  Ptiicussmg  Lue  Right  Apex. 


needs  to  press  very  firmly  Avith  th'e  middle  finger  of  the  left  hand 
upon  the  surface  of  the  chest,  so  firmly  that  if  the  patient  is  sitting 
upon  a  stool  without  support  for  his  back,  it  will  need  considerable 
exertion  upon  his  part  to  avoid  losing  his  balance. 


60       PHYSIC  J  L  DIAGNOSIS   OF  DISEASES  OF  THE  CHEST. 


In  percussing  the  front  of  the  chest  it  is  important  to  have  the 
patient  sitting  or  lying  in  a  symmetrical  j^'^sition — that  is,  without 
axiy  twist  or  tilting  to  one  side.  His  head  should  point  straight 
forward  and  his  muscles  must  he  thoroughly  relaxed.  Many  pa- 
tients, when  stripped  for  examination,  sAvell  out  their  chests  and 


1 


Fig.  39.— Position  of  the  Hands  Wlien  Perrussing  the  Left  Apex. 

sit  up  with  a  military  erectness.  The  muscular  tension  thus  i^ro- 
dueed  modifies  the  percussion  note  and  causes  an  embarrassing 
multitude  of  muscle  sounds  which  greatly  disturb  auscultation. 

Having  i)laced  tlie  patient  in  an  easy  and  symmetrical  position, 
our  percussion  should  proceed  according  to  the  following  r\iles : 

(1)  Always  press  as  firmly  as  jiossible  upon  the  surface  of  the 


PERCUSSION.  61 

chest  with  the  second  finger  of  the  left  hand '  on  the  dorsum  of 
which  the  blow  is  to  be  struck.  Raise  the  other  fingers  of  the  left 
hand  from  the  chest  so  as  not  to  interfere  with  its  vibrations. 

(2)  Strike  a  quick,  perpendicular,  rebounding  blow  with  the  tip 
of  the  second  finger'''  of  the  right  hand  upon  the  second  finger  of  the 
left  just  behind  the  nail,  imitating  as  far  as  possible  with  the  right 
hand  the  action  of  a  piano-hammer.     The  quicker  the  percussing 


Fig.  40.— The  Right  Way  to  Percuss— i.  e..  From  the  Wrist. 

finger  gets  away  again  after  striking,  the  clearer  will  be  the  note 
obtained. 

(3)  Let  all  the  blows  struck  in  any  one  part  of  the  chest  be 
uniform  in  force. 

1  Left-handed  percussors  will,  of  course,  keep  the  right  hand  upon  the 
chest  and  strike  with  the  left. 

-  When  percussing  the  right  apex  I  prefer  to  strike  upon  the  thumb  (see 
Figs.  38  and  39)  as  it  is  almost  impossible  when  standing  directly  in  front 
of  the  patient  to  fit  any  of  the  fingers  comfortably  into  the  right  supraclavicular 
fossa. 


62       PHYSICAL  DIAGNOSIS  OF  DISEASES   OF  THE  CHEST. 

(4)  Strike  from  the  wrist  and  not  from  the  elbow  (see  Figs.  40 
and  41).     The  wrist  must  be  held  perfectly  loose. 

(5)  Keep  the  percussing  finger  bent  at  a  right  angle  as  in  Fig. 
42. 

The  force  to  be  used  in  percussion  depends  upon  the  purpose 


Fig.  41.— The  Wrong  Way  to  Percuss -f.  e.,  From  the  Elbow. 

for  which  the  percussion  is  used — that  is,  upon  Avhat  organ  we  are 
percussing — and  also  upon  the  thickness  of  the  muscles  covering 
that  part  of  the  chest.  For  example,  it  is  necessary  to  percuss 
very  strongly  when  examining  the  back  of  a  muscular  man,  where 
an  inch  or  two  of  muscle  intervenes  between  the  finger  on  which 


PERCUSSION. 


63 


we  strike  and  the  lung  from  which  we  desire  to  elicit  a  sound. 
Over  the  front  of  the  chest  and  in  the  axillae  the  muscular  covering 
is  much  thinner,  and  hence  a  lighter  blow  suffices.  In  children  or 
emaciated  patients,  or  in  any  case  in  which  the  muscular  develop- 
ment is  slight,  percussion  should  be  as  light  as  is  sufficient  to  elicit  a 
clear  sound.  Heavy  percussion  is  sometimes  necessary  but  always 
unsatisfactory,  in  that  the  sound  which  it  elicits  comes  from  a  rela- 
tively large  area  of  the  chest  and  does  not  therefore  give  us  infor- 


Fio.  42.— Proper  Position  of  the  Right  Hand  During  Percussion. 


mation  about  the  condition  of  any  sharply  localized  area.  If  a  car- 
penter, in  tapping  the  Avail  to  find  the  position  of  the  studs,  strikes 
too  hard,  he  will  fail  to  find  the  beam,  because  the  blow  delivered 
over  the  spot  behind  which  the  beam  is  situated  is  so  forcible  as  to 
bring  out  the  resonance  of  the  hollow  parts  around.  It  is  the  same 
with  medical  percussion.  Heavy  percussion  is  always  inaccurate.' 
It  may  be  necessary  where  the  muscles  are  very  thick,  but  its  value 

'  See  also  below,  page  76,  the  lung  reflex. 


64       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

is  then  proportionately  diminished.  On  the  other  hand,  it  is  pos- 
sible to  strike  so  lightly  that  no  recognizable  sound  is  elicited  at 
all.  The  best  percussion,  therefore,  is  that  which  is  just  forcible 
enough  to  elicit  a  clear  sound  without  setting  a  large  area  of  chest 
wall  in  vibration. 

The  position  of  the  patient  above  described  applies  to  percus- 
sion of  the  front.     When  we  desire  to  percuss  the  back,  it  is  ian- 


FiG.  43.- Proper  Position  of  the  Patient  During  Percussion  of  the  Back. 


portant  to  get  the  scapulae  out  of  the  way  as  far  as  possible,  since 
we  cannot  get  an  accurate  idea  of  sounds  transmitted  through  them. 
To  accomplish  this,  we  put  the  patient  in  the  position  shown  in 
Fig.  43,  the  arms  crossed  upon  the  chest  and  each  hand  upon  the 
opposite  shoulder.  The  patient  should  be  made  to  bend  forward ; 
otherwise  the  left  hand  of  the  percussor  will  be  uncomfortably  bent 
backward  and  his  attention  thereby  distracted  (see  Fig.  44). 

When  the  axillae  are  to  be  percussed,  the  patient  should  put  the 
hands  upon  the  top  of  the  head. 


PERCUSSION. 


65 


(b)  Auscultatory  Percussion. 

If  while  percussing  one  auscults  at  the  same  time,  letting  the 
chest  piece  of  the  stethoscope  rest  upon  the  chest,  or  getting  the 
patient  or  an  assistant  to  hold  it  there,  the  sounds  produced  by 
percussion  are  greatly  intensified,  and  changes  in  their  volume, 
pitch,  or  quality  are  very  readily  appreciated.     The  blows  must  be 


Fig.  44.— Wrong  Position  for  Percussing  the  Back.    The  patient  should  be  bent  forward. 

very  lightly  struck,  either  upon  the  chest  itself  or  upon  the  finger 
used  as  a  2)leximeter  in  the  ordinary  way.  Some  observers  use  a 
short  stroking  or  scratching  touch  upon  the  chest  itself  without 
employing  any  pleximeter. 

This  method  is  used  especially  in  attempting  to  map  out  the 
borders  of  the  heart  and  in  marking  the  outlines  of  the  stomach. 
In  the  hands  of  skilled  observers  it  often  yields  valuable  results, 
6 


66       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

but  one  source  of  error  must  be  especially  guarded  against.  The 
line  along  which  we  2>^>'ci(ss,  when  approaclilnfj  an  organ  ichose  bor- 
ders tve  desire  to  mark  oiit,  must  neither  approach  the  chest  pjiece  of 
the  stethoscojye  nor  recede  from  it.  In  other  words,  the  line  along 
which  we  percuss  must  always  describe  a  segment  of  a  circle  whose 
centre  is  the  chest  piece  of  the  stethoscojie  (see  Fig.  45).  If  we 
percuss,  as  we  ordinarily  do,  in  straight  lines  toward  or  away  from 
the  border  of  an  organ,  our  results  are  wholly  unreliable  since 
every  straight  line  must  bring  the  point  percussed  either  closer  to 


Percussion  arc. 


Chest-piece  of 
Stethoscope. 


Fig.  45.— Auscultatory  Percussion,  Showing  the  Arc  along  which  such  Percussion  should  be 

made. 


the  stethoscope  or  farther  from  it,  and  the  intensity  and  quality 
of  the  sounds  conducted  through  the  instrument  to  our  ears  vary 
directly  with  its  distance  from  the  point  percussed. 

It  will  be  readily  seen  that  the  usefubiess  of  auscultatory  per- 
cussion is  limited  by  this  source  of  error,  and  that  considerable 
practice  is  necessary  before  one  can  get  the  best  results  from  this 
method.  Nevertheless  it  has,  I  believe,  a  place,  though  not  a  very 
important  one,  among  serviceable  methods  of  physical  examination. 


PERCUSSION. 


G7 


(c)  PaliKitory  Percussion. 

Some  German  observers  use  a  method  of  percussion  in  which 
attention  is  fixed  directly  or  primarily  on  the  amount  of  resistance 
offered  by  the  tissues  over  which  percussion  is  made.  Even  in  or- 
dinary percussion  the  amount  of  resistance  is  always  noted  by 
experienced  percussors,  but  the  element  in  sound  is  usually  the 
main  object  of  attention.  Palpatory  percussion  is  rather  a  series 
of  short  pushes  against  various  points  on  the  chest  wall,  but  some 


Normal     dulness 
of  the  right  apex. 


Liver  dulness.    ' 


Liver  flatness. 


Deep  cardiac 
dulness. 


Superficial  cardiac 
dulness. 


Traube's  semilu- 
nar tympanitic 
space. 


Fig.  46.— Percussion  Outlines  in  the  Normal  Chest. 

sound  is  elicited  and  probably  enters  into  the  rather  comj)lex  judg- 
ment which  follows. 

In  this  country  palpatory  percussion  is  but  little  employed. 


II.  Percussion  Resonance  of  the  Normal  Chest. 

The  note  obtained  by  percussing  the  normal  chest  varies  a  great 
deal  in  different  areas.  In  Fig.  46,  the  parts  shaded  darkest  are 
those  that  normally  give  least  sound  when  percussed  in  the  manner 
described  above,  while  from  the  lightest  areas  the  loudest  and  clear- 
est sound  may  be  elicited. 


68       PHYSICAL  DIAG^VSIS  OF  DISEASES  OF  THE  CHEST. 


^^'-  Upper  lobe. 


^--  Lower  lobe. 


f_ _-  Splenic  area. 


(a)  The  sound  elicited  in  the  latter  areas  is  known  as  normal  or 
"vesicular"  resonance,  and  is  due  to  the  presence  of  a  normal 
amount  of  air  in  the  vesicles  of  the  lung  underneath.  If  this  aii- 
contauiuig  lung  is  replaced  by  a  fluid  or  solid  medium,  as  in  pleu- 
ritic effusion  or  pneumonia,  it  is  much  more  diflicult  to  elicit  a 
sound,  and  such  sound  as  is  produced  is 
short,  high  pitched,  and  has  a  feeble  carry- 
ing power  when  compared  Avith  the  sound 
elicited  from  the  normal  lung.  This 
short,  feeble,  high-pitched  sound  is 
known  technically  as  a  ^^ dull"  or 
^^flat"  sound,  flatness  designating 
the  extreme  of  the  qualities  that 
characterize  dulness.  Over  the 
parts  shaded  dark  in  Fig.  46,  we 
normally  get  a  dull  or  flat  tone,  the  darkest 
portions  being  flat  and  the  others  dull. 
The  heavy  shadow  on  the  right  corresponds 
to  the  position  occupied  by  the  liver,  or 
rather  by  that  part  of  it  which  is  m  imme- 
diate contact  with  the  chest  w^all.  The  up- 
per portion  of  the  liver  is  overlapped  by  the 
right  lung  (see  Fig.  46),  and  hence  at  this 
jioint  we  get  a  certain  amount  of  resonance 
on  percussion,  although  the  tone  is  not  so 
clear  as  that  to  be  obtained  higher  up.  Be- 
loAV  the  sixth  rib  we  find  true  flatness  near 
the  sternum  and  for  a  few  inches  to  the  right 
of  this  point.  As.'we  go  toward  the  axilla, 
the  line  of  lung  resonance  slopes  down,  as  is  seen  in  Fig.  47.  In 
the  back  resonance  extends  to  the  ninth  or  tenth  ribs. 


Fig 


47.— Position  of  the  Left 
Lung  in  the  A.xllla. 


Normal  Dull  Areas. 

{b)  On  the  left  side,  the  main  dull  area  corresponds  to  the  heart, 
which  at  this  pomt  approaches  the  chest  wall,  and  over  the  por- 
tion shaded  darkest  is  uncovered  by  the  lung.     The   part   here 


PERCUSSION.  69 

lightly  shaded  corresponds  to  that  portion  of  the  heart  Avhicli  is 
overlapped  by  the  margm  of  the  right  and  left  lungs. 

Over  the  portion  of  the  heart  not  overlapped  by  the  lung  (see 
Fig.  46,  p.  67)  the  percussion  note  is  nearly  flat  to  light  percus- 
sion, and  very  dull  even  when  strongly  percussed.  This  little 
quadrangular  area  is  known  as  the  ^^  superficial  cardiac  s2Mce,^^  and 
the  dulness  corresponding  to  it  is  referred  to  as  the  "svperficial'' 
cardiac  dulness,  while  the  dulness  corresponding  to  the  outlines  of 
the  heart  itself  beneath  the  overlapping  lung  niargms  is  called  the 
"deep"  cardiac  dulness. 

When  the  heart  becomes  enlarged,  both  of  these  areas,  the  deep 
and  the  superficial,  are  enlarged,  the  former  corresponding  to  the 
increased  size  of  the  heart  itself,  while  the  superficial  cardiac  space 
is  extended  because  the  margins  of  the  lungs  are  pushed  aside  and 
a  larger  piece  of  the  heart  wall  conies  in  contact  with  the  chest 
wall.  Accordingly,  either  the  superficial  or  the  deep  dulness  may 
be  mapped  out  as  a  means  of  estimating  the  size  of  the  heart. 
Each  method  has  its  advantages  and  its  advocates.  The  superficial 
dulness  is  easier  to  map  out,  but  varies  not  only  with  the  size  of  the 
heart,  but  with  the  degree  to  which  the  lungs  are  distended  with 
air,  or  adherent  to  the  pericardium  or  chest  wall.  What  we  are 
percussing  is  in  fact  the  borders  of  the  lungs  at  this  pouit. 

On  the  other  hand,  the  deep  cardiac  dulness  is  much  more  satis- 
factory as  a  means  of  estimating  ihe  size  of  the  heart  but  much 
more  difficult  to  map  out.  It  needs  a  trained  ear  and  long  practice 
to  percuss  out  correctly  the  borders  of  the  heart  itself,  especially 
the  right  and  the  upper  borders,  since  here  we  have  to  percuss 
over  the  sternum  where  differences  of  resonance  are  very  deceptive 
and  difficult  to  perceive. 

It  is  a  disputed  point  whether  light  or  forcible  percussion  should 
be  used  when  we  attempt  to  map  out  the  deep  cardiac  dulness. 
Heavy  percussion  is  believed  by  its  advocates  to  penetrate  through 
the  overlapping  lung  margins  and  bring  out  the  note  corresponding 
to  the  heart  beneath,  a  note  which,  they  say,  is  missed  altogether 
by  light  percussion.  On  the  other  hand,  those  who  employ  light 
percussion  contend  that  heavy  percussion  sets  in  vibration  so  large 


70       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

ail  area  of  lung  superficially  that  fine  distinctions  of  note  are  made 
impossible  (see  above,  ]3.  63). 

Good  observers  are  to  be  found  on  each  side  of  this  question, 
and  I  have  no  doubt  that  either  method  works  well  in  skilled 
hands.     Personally  I  have  found  light  percussion  preferable. 

"Whatever  method  we  use  we  must  percuss  successive  points 
along  a  line  running  at  right  angles  to  the  border  of  the  organ 
which  we  wish  to  outline  until  a  change  of  note  is  perceived. 
Thus,  if  we  wish  to  percuss  out  the  upper  border  of  the  liver,  we 
strike  successive  jiouits  along  a  line  running  parallel  to  the  ster- 
num and  about  an  inch  to  the  right  of  it. '  AMien  a  change  of  note 
is  perceived,  the  j)oint  should  be  marked  with  a  skin  pencil ;  then 
we  percuss  along  a  line  parallel  to  the  first  one,  and  perhaps  an 
inch  farther  out,  and  again  mark  with  a  dot  the  point  at  which  the 
note  first  changes.  A  line  connecting  the  j^oints  so  marked  upon 
the  skin  represents  the  border  of  the  organ  to  be  outlmed. 

If  now  we  look  at  the  upper  part  of  the  chest  in  Fig.  46,  we 
notice  at  once  that  the  two  sides  are  not  shaded  alike :  the  left  apex 
is  distinctly  lighter  colored  than  the  right.  This  is  a  very  impor- 
tant point  and  one  not  sufficiently  appreciated  by  students.  The 
apex  of  the  normal  right  lung  is  distinctly  less  resonant  than  the 
apex  of  the  left  in  a  corresponding  position. 

In  jjercussing  at  the  bottom  of  the  left  axilla,  we  come  upon  a 
small  oval  ai'ea  of  dulness  corresponding  to  that  outlined  in  Fig.  47. 
This  is  the  area  of  sjdenic  dulness^  so  called,  and  corresponds  to 
that  portion  of  the  spleen  which  is  in  contact  with  the  chest  wall. 
This  dull  area  is  to  be  made  out  only  in  case  the  stomach  and  colon 
are  not  overdistended  with  air.  AMien  these  organs  are  ivll  of  gas 
as  is  not  infrequently  the  case,  there  is  no  area  of  splenic  dulness 
and  the  whole  region  gives  forth,  when  percussed,  a  note  of  a  qual- 
ity next  to  be  described,  namely,  'tympanitic." 

(c)  Tympanitic  resonance  is  that  obtained  over  a  hollow  body, 
like  the  stomach  or  the  colon  when  distended  with  air.  It  is  usu- 
ally of  a  higher  pitch  than  the  resonance  to  be  obtained  over  the 

'  Or  we  may  reverse  the  procedure  ;  percuss  first  over  the  liver  and  then 
work  toward  the  lung  above  until  the  note  becomes  more  resonant. 


PERCUSSION.  71 

normal  lung,  and  may  be  elicited  by  percussion  lighter  than  that 
needed  to  bring  out  the  lung  resonance.  It  differs  also  from  the 
vesicular  or  pulmonary  resonance  in  qualiti/,  in  away  easy  to  appre- 
ciate but  difficult  to  describe.  Tympanitic  resonance  is  usually  to 
be  heard  when  one  percusses  over  the  front  of  the  left  chest  near 
the  ensiform  cartilage  and  for  a  few  inches  to  the  left  of  this  point 
over  an  area  corresponding  with  that  of  the  stomach  more  or  less 
distended  with  air.  This  tympanitic  area,  known  as  "  Tmube^s 
semilunar  space,"  varies  a  great  deal  in  size  according  to  the  contents 
of  the  stomach.  It  is  bounded  on  the  right  by  the  liver  flatness, 
above  by  the  pulmonary  resonance,  on  the  left  by  the  splenic  dul- 
ness,  and  below  by  the  resonance  of  the  intestine,  which  is  also 
tympanitic,  although  its  pitch  is  different  owing  to  the  different 
size  and  shape  of  the  intestine. 

(The  right  axilla  shows  normal  lung  resonance  down  to  the 
point  at  which  the  liver  flatness  begins,  as  shown  in  Fig.  4.) 

In  the  back,  when  the  scapulse  are  drawn  forward,  as  shown  in 
Fig.  43,  page  64  percussion  elicits  a  clear  vesicular  resonance  from  top 
to  bottom  on  each  side,  although  the  top  of  the  right  lung  is  always 
slightly  less  resonant  than  the  top  of  the  left,  and  sometimes  the 
bottom  of  the  right  lung  is  slightly  less  resonant  than  the  corre- 
siDonding  portion  of  the  left,  on  account  of  the  presence  of  the  liver 
on  the  right. 

It  should  be  remembered,  however,  that  in  the  majority  of  cases 
the  resonance  throughout  the  back  is  distinctly  less  than  that  ob- 
tained over  the  front,  on  account  of  the  greater  thickness  of  the 
back  muscles.  Yet  in  children  or  emaciated  persons,  or  where  the 
muscular  development  is  slight,  there  may  be  as  much  resonance 
behind  as  in  front. 

Importance  of  Percussing  Symmetrical  Points. — Since  we  depend 
for  our  standard  of  resonance  upon  comparison  with  a  similar  spot 
on  the  outside  of  the  chest,  it  is  all-important  that  in  making  such 
comparisons  we  should  percuss  symmetrical  points,  and  not,  for 
example,  compare  the  resonance  over  the  third  rib  in  the  right  front 
with  that  over  the  third  interspace  on  the  left,  since  more  resonance 
can  always  be  elicited  over  an  interspace  than  over  a  rib.     This 


72       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

comparison  of  symmetrical  points,  however,  is  interfered  with  by 
the  presence  of  the  heart  on  one  side  and  the  liver  on  the  other,  as 
well  as  by  the  fact  that  the  apex  of  the  right  lung  is  normally  less 
resonant  than  that  of  the  left  A  resonance  which  would  be  patho- 
logically feeble  if  obtained  over  the  left  top  may  be  normal  over  the 
right  "NMiere  both  sides  are  abnormal,  as  in  bilateral  disease  of 
the  lung,  or  where  fluid  accumulates  in  both  pleural  cavities,  we 
have  to  make  the  best  comparison  Ave  can  between  the  sound  in  the 
given  case  and  an  ideal  standard  carried  in  the  mind. 

It  must  always  be  remembered  that  the  amount  of  resonance 
obtained  at  any  point  by  percussion  depends  upon  how  hard  one 
strikes,  as  well  as  upon  the  conditions  obtaining  within  the  chest. 
A  powerful  blow  over  a  diseased  lung  may  bring  out  more  reso- 
nance than  a  lighter  blow  over  a  normal  lung.  To  strike  with  per- 
fect fairness  and  with  equal  force  upon  each  side  can  be  learned  only 
by  considerable  practice.  Furthermore,  the  distance  from  the  ear 
to  each  of  the  two  points,  the  resonance  of  which  we  are  compar- 
ing, must  be  the  same — that  is,  we  must  stand  squarely  in  front  or 
squarely  behind  the  patient,  otherAvise  the  note  coming  from  the 
part  farther  from  the  ear  Avill  sound  duller  than  that  coming  from 
the  nearer  side. 

The  normal  resonance  of  the  different  parts  of  the  chest  can  be 
considerably  modified  by  the  position  of  the  patient,  by  deep  breath- 
ing, by  muscular  exertion,  and  by  other  less  important  conditions. 
If,  for  example,  the  patient  lies  upon  the  left  side,  the  heart  swings 
out  toAvard  the  left  axilla  and  its  dulness  is  extended  in  the  same 
direction.  Deep  inspiration  pushes  forAvard  the  margins  of  the 
lungs  so  that  they  encroach  upon  and  reduce  the  area  of  the  heart 
dulness  and  liA^er  dulness.  After  muscular  exertion  the  lungs  be- 
come more  than  ordinarily  A'oluminous,  OAving  to  the  temporary  dis- 
tention brought  about  by  the  unusual  amount  of  Avork  throAAai  upon 
them. 

The  area  of  cardiac  dulness  is  increased  in  any  condition  iuA'olv- 
ing  insufficient  lung  expansion.  Thus,  in  children,  in  debility, 
chlorosis,  or  fevers,  the  space  occupied  by  the  lungs  is  relatiA^ely 
small  and  the  dull  areas  corresponding  to  the  heart  and  liA'er  are 


PERCUSSION.  73 

proportionately  enlarged.  In  old  age,  on  the  other  hand,  when  the 
lungs  have  lost  part  of  their  elasticity  and  sag  down  over  the  heart 
and  liver,  the  percussion  dulness  of  these  organs  is  reduced. 

Conditions  Modifying  the  Percussion  Note  in  Health. — The  de- 
velopment of  muscle  or  fat  as  well  as  the  thickness  of  the  chest 
wall  will  influence  greatly  the  amount  of  resonance  to  be  obtained 
by  percussion.  Indeed,  we  see  now  and  then  an  individual  in  no 
part  of  whose  chest  can  any  clear  percussion  tone  be  elicited.  In 
women,  the  amount  of  development  of  the  breasts  has  also  great 
influence  upon  the  percu^ssion  note.  In  children,  the  note  is  gener- 
ally clearer,  and  only  the  lightest  percussion  is  to  be  used  on  ac- 
count of  the  thinness  of  the  chest  wall.  In  old  people  whose  lungs 
are  almost  ahvays  more  or  less  emphysematous,  a  shade  of  tym- 
panitic quality  is  added  to  the  normal  vesicular  resonance.  The 
distention  of  the  colon  wdth  gas  may  obliterate  the  liver  dulness  by 
rotating  that  organ  so  that  only  its  edge  is  in  contact  with  the  chest 
wall,  and  if  there  is  wind  in  the  stomach,  a  variable  amount  of 
tympany  is  heard  on  percussing  the  lower  left  front  and  axilla  or 
even  on  the  left  back. 

If  a  patient  is  examined  while  lying  on  the  side  the  amount  of 
resonance  over,  the  lung  corresponding  to  the  side  on  which  he 
lies  is  usually  less  than  that  of  the  side  which  is  uppermost,  because 
there  is  more  air  in  the  latter.  Whatever  the  patient's  position, 
the  amount  of  resonance  is  also  greater  at  the  end  of  inspiration 
than  at  the  end  of  expiration,  for  the  reason  just  given.  As  the 
lungs  expand  with  full  inspiration,  their  borders  move  so  as  to 
cover  a  larger  portion  of  the  organs  which  they  noi*mally  overlap. 
Portions  of  the  chest  which  at  the  end  of  expiration  are  dull  or 
flat,  owing  to  the  close  juxtaposition  of  the  heart,  liver,  or  spleen, 
become  resonant  at  the  end  of  inspiration.  For  example,  the  lower 
margin  of  the  right  lung  moves  down  during  inspiration  so  as  to 
cover  a  considerably  larger  portion  of  the  liver. 

Percussion  as  a.  Means  of  Ascertahiing  the  MovahiUty  of  the  Lung 
Borders. — It  is  often  of  great  importance  to  determine  not  merely 
the  position  of  the  resting  lung  but  its  power  to  expand  freely. 
This  can  be  ascertained  by  percussion  in  the  following  way :  The 


74       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

lower  border  of  the  lung  resonance,  say  in  the  axilla,  is  carefully 
marked  out.  Then  percussion  is  made  over  a  point  just  below  the 
level  of  the  resting  lung  and  at  the  same  time  the  patient  is  directed 
to  inspire  deeply  If  the  lung  expands  and  its  border  moves  down, 
the  percussion  note  will  change  suddenly  from  dull  to  resonant 
during  the  inspiration.  An  excursion  of  two  or  three  inches  can 
often  be  demonstrated  by  this  method,  which  is  especially  impor- 
tant for  the  anterior  and  posterior  margins  of  the  lung.  In  the 
axilla  Litten's  phrenic  shadow  will  give  us  the  same  information. 

The  mobility  of  the  borders  of  the  lung,  as  determined  by  this 
method,  is  of  considerable  clinical  importance,  for  an  absence  of 
such  mobility  may  indicate  pleuritic  adhesions.  Its  amount  de- 
pends iipon  various  conditions  and  varies  much  in  different  indi- 
viduals, but  complete  absence  of  mobility  is  always  pathological. 

(d)  Cracked-Pot  Resonance 

When  percussing  the  chest  of  a  crying  child,  we  sometimes 
notice  that  the  sound  elicited  has  a  peculiar  ^^  cltinkuuj  ^^  quality, 
like  that  produced  by  strikmg  one  coin  with  another,  but  more 
muffled.  The  sound  may  be  more  closely  imitated,  and  the  mode 
of  its  production  illustrated,  by  clasping  the  hands  palm  to  pabn 
so  as  to  enclose  an  air  space  which  communicates  with  the  outer  air 
through  a  chink  left  open,  and  then  striking  the  back  of  the  under 
hand  against  the  knee  By  the  blow,  air  is  forced  out  through  the 
chink  with  a  sound  like  that  of  metallic  coins  struck  together. 

In  disease,  the  cracked-pot  sound  is  usually  produced  over  the 
pulmonary  cavity  (as  in  advanced  phthisis)  from  which  the  air  is 
suddenly  and  forcibly  expelled  by  the  percussion  stroke. 

It  is  much  easier  to  hear  this  peculiar  sound  if,  while  percuss- 
ing, one  listens  with  a  stethoscope  at  the  patient's  open  mouth. 
The  patient  himself  holds  the  chest  piece  of  the  instrument  just  in 
front  of  his  open  mouth,  leaving  the  auscultator's  hands  free  for 
percussing. 


PERCUSSION.  76 

(e)  Amphoric  Resonance. 

A  low-pitched  hollow  sound  approximating  in  quality  to  tym- 
panitic resonance,  and  sometimes  obtained  over  pulmonary  cavities 
or  over  pneumothorax,  has  received  the  name  of  amphoric  reso- 
nance It  may  be  imitated  by  percussing  the  trachea  or  the  cheek 
distended  with  air 

Summary 

The  varieties  of  resonance  to  be  obtained  by  percussing  the  nor- 
mal thorax  are ; 

(1)  Vesicular  resonance,  to  be  obtained  over  normal  lung  tissue. 

(2)  Tympanitic  resonance,  to  be  obtained  in  Traube's  semilunar 
space 

(3)  Diminished  resonance  or  dulness,  such  as  is  present  over  the 
scapulae,  and 

(4)  Absence  of  resonance  or  flatness,  such  as  is  discovered  when 
we  percuss  over  the  lowest  ribs  in  the  right  front 

(5)  Crached-pot  resonance,  sometimes  obtainable  over  the  chest 
of  a  crying  child. 

(6)  Amphoric  resonance,  obtainable  over  the  trachea. 

Any  of  these  sounds  may  denote  disease  if  obtained  in  portions 
of  the  chest  where  they  are  not  normally  found.  Each  has  its 
place,  and  hecomes  patholofjical  if  found  elsewhere.  Tympanitic  reso- 
nance is  normal  at  the  bottom  of  the  left  front  and  axilla,  but  not 
elsewhere.  Dulness  or  flatness  is  normal  over  the  areas  corre- 
sponding to  the  heart,  liver,  and  spleen,  and  over  the  scapulae,  but 
not  elsewhere  unless  the  muscular  covering  of  the  chest  is  enor- 
mously thick.  Vesicular  resonance  is  normal  over  the  areas  corre- 
sponding to  the  lungs,  but  becomes  evidence  of  disease  if  found 
over  the  cardiac  or  hepatic  areas. 

Cracked-pot  resonance  may  be  normal  if  produced  while  per- 
cussing the  chest  of  a  child,  but  under  all  other  conditions,  so  far 
as  is  known,  denotes  disease. 

Amphoric  resonance  always  means  disease,  usually  pulmonary 
cavity  or  pneumothorax,  if  found  elsewhere  than  over  the  trachea. 


76       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 


(/)    The  Lung  Reflex. 

It  must  also  be  remembered,  when  percussing,  that  in  some  eases 
every  forcible  percussion  bloAv  increases  the  resonance  to  be  ob- 
tained by  subsequent  blovrs.  Any  one  who  has  demonstrated  an 
area  of  percussion  dulness  to  many  students  in  succession  must 
have  noticed  occasionally  that  the  more  we  percuss  the  dull  area, 
the  more  resonant  it  becomes,  so  that  to  those  who  last  listen  to 
the  demonstration  the  difference  which  we  wish  to  bring  out  is  much 
less  obvious  than  to  those  who  heard  the  eaiiiest  percussion  strokes. 
Abrams  has  referred  to  this  fact  under  the  name  of  the  "  lung  re- 
flex," believing,  partly  on  the  evidence  of  fluoroscopic  examination, 
that  if  an  irritant  such  as  cold  or  mustard  is  applied  to  any  part  of 
the  skm  covering  the  thorax,  the  lung  expands  so  that  a  localized 
temporary  emphysema  is  produced  in  response  to  the  irritation. 
Apparently  percussion  has  a  similar  effect. 

III.   Sexse  of  Resistaxce. 

While  percussing  the  chest  we  must  be  on  the  lookout  not  only 
for  changes  in  resonance,  but  for  variations  in  the  amount  of  resist- 
ance felt  underneath  the  finger.  Normally  the  elasticity  of  the 
chest  walls  over  the  upper  fronts  is  considerably  greater  and  the 
sense  of  resistance  considerably  less  than  that  felt  over  the  liver. 
In  the  axillae  and  over  those  jiortions  of  the  back  not  covered  by 
the  scapulae,  we  feel  in  normal  chests  an  elastic  resistance  when 
percussing  which  is  in  contrast  Avith  the  dead,  woodeny  feeling 
which  is  communicated  to  the  finger  when  the  air-containing  lung 
is  replaced  by  fluid  or  solid  contents  (pleuritic  effusion,  pneu- 
monia, phthisis,  etc.).  In  some  physicians  this  sense  of  resistance 
is  very  highly  developed  and  as  much  information  is  obtained 
thereby  as  through  the  sounds  elicited.  As  a  rule,  however,  it  is 
only  by  long  practice  that  the  sense  of  resistance  is  cultivated  to  a 
point  where  it  becomes  of  distinct  use  in  diagnosis. 


Jo   ^^ 


CHAPTER  IV. 

AUSCULTATION. 

Auscultation  may  be  practised  by  placing  one's  ear  directly 
against  the  patient's  chest  (immediate  auscultation)  or  with  the 
help  of  a  stethoscope  (mediate  auscultation). 

Each  method  has  its  place.  Immediate  auscultation  is  said  to 
have  advantages  similar  to  those  of  the  low  power  of  the  micro- 
scope, in  that  it  gives  us  a  general  idea  of  the  condition  of  a  rela- 
tively large  area  of  tissue,  Avhile  the  stethoscope  may  be  used,  like 
the  oil  immersion  lens,  to  bring  out  details  at  one  or  another  point. 

On  the  other  hand,  I  have  heard  it  said  by  E.  C.  Janeway  and 
other  accomplished  diagnosticians  that  the  unaided  ear  can  perceive 
sounds  conducted  from  the  interior  of  the  king — sounds  quite  inau- 
dible with  any  stethoscope — and  that  in  this  way  deepseated  areas 
of  solidification  may  be  recognized. 

Immediate  auscultation  may  be  objected  to 

(a)  On  grounds  of  deikacy  (when  examining  persons  of  the 
opposite  sex). 

{h)  On  grounds  of  cleanliness  (although  the  chest  may  be  cov- 
ered with  a  towel  so  as  to  protect  the  auscultator  to  a  certain 
extent). 

(c)  Because  we  cannot  conveniently  reach  the  supraclavicular 
or  the  upper  axillary  regions  in  this  way. 

{(l)  Because  it  is  difficult  to  localize  the  different  valvular  areas 
and  the  sites  of  cardiac  murmurs  if  immediate  auscultation  is  em- 
ployed. 

On  account  of  the  latter  objection  the  great  majority  of  observ- 
ers now  use  the  stethoscope  to  examine  the  heart.  For  the  lungs, 
both   methods   are   employed    by  most   experienced   auscultators. 


78       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

(Personally,  I  have  never  yet  learned  to  hear  anything  with  my 
unaided  ear  Avhich  I  could  not  hear  better  with  a  stethoscope,  and 
the  Bowles  stethoscope  seems  to  me  to  reach  as  large  an  area  and 
as  deep  as  the  unaided  ear.  Nevertheless  the  weight  of  competent 
opinion  is  against  me  and  greater  experience  will  doubtless  show 
me  my  mistake.) 

"VMiile  learning  the  use  of  immediate  auscultation  it  is  best  to 
close  Avith  the  fingers  the  ear  which  is  not  in  contact  with  the  chest. 
With  practice  one  comes  to  disregard  outer  noises  and  does  not 
need  to  stop  the  ear. 

Mediate  Auscultatiox. 

1.   Selection  of  a  Stethoscope. 

(1)  It  is  as  rash  for  an}^  one  to  select  a  stethoscope  without  first 
trying  the  fit  of  the  ear  pieces  in  his  ears  as  it  would  be  to  buy  a 
new  hat  Avithout  trying  it  on.  What  suits  A.  very  well  is  quite  im- 
possible for  B.  It  is  true  that  one  can  get  used  to  almost  any 
stethoscope  as  one  can  to  almost  any  hat,  but  it  is  not  necessary  to 
do  so.  The  ear  pieces  of  the  ordinary  stethoscope  are  often  too 
small  and  rarely  too  large.  In  ease  of  doubt,  therefore,  it  is  better 
to  err  upon  the  side  of  getting  a  stethoscope  with  too  large  rather 
than  too  small  ends. 

(2)  The  binaural  stethoscope,  which  is  now  almost  exclusively 
used  in  this  country,  maintains  its  position  in  the  ears  of  the  aus- 
cultator  either  through  the  pressure  of  a  rubber  strap  stretched 
around  the  metal  tubes  leading  to  the  ears,  or  by  means  of  a  steel 
spring  connecting  the  tvibes.  Either  variety  is  usually  satisfactory, 
but  I  prefer  a  stethoscope  made  with  a  steel  spring  (see  Fig.  48) 
because  such  a  spring  is  far  less  likely  to  break  or  lose  its  elasticity 
than  a  rubber  strap.  A  rubber  strap  can  always  b^  added  if  this 
is  desirable.  It  is  important  to  pick  out  an  instrument  possessing 
a  spring  not  strong  enough  to  cause  pain  in  the  external  meatus  of 
the  ear  and  yet  strong  enough  to  hold  the  ear  pieces  firmly  in  place. 
Persons  with  narrow  heads  need  a  much  more  powerful  spring  or 
strap  than  would  be  convenient  for  persons  with  wide  heads. 


AUSCULTATION. 


79 


(3)  The  rubber  tubing  used  to  join  the  metallic  tubes  to  the 
chest  piece  of  the  instrument  should  be  as  flexible  as  possible  (see 
Fig.  48).  Stiff  tubing  (see 
rig.  49)  makes  it  necessary 
for  the  auscultator  to  move 
his  head  and  body  from 
place  to  place  as  the  exam- 
ination of  the  chest  pro- 
gresses, while  if  flexible 
tubing  is  used  the  head  need 
seldom  be  moved  and  a  great 
deal  of  time  and  fatigue  is 
thus  saved.  Stiff  stetho- 
scopes are  especially  incon- 
venient when  examining  the 
axilla. 

(4)  Jointed  stethoscopes 
which  fold  up  or  take  apart 
should  be  scrupulously 
avoided.  They  are  a  delu- 
sion and  a  snare,  apt  to 
come  apart  at  critical  mo- 
ments, and  to  snap  and  creak 
at  the  joints  when  in  use, 
sometimes  producing  in  this  way  sounds  which 
may  be  easily  mistaken  for  rales.  Such  an  in- 
strument is  no  more  portable  nor  compact  than 
the  ordinary  form  with  flexible  tubes.  It  has, 
therefore,  no  advantages  over  stethoscopes  made 
in  one  piece  and  possesses  disadvantages  which 
are  peculiarly  annoymg. 

(5)  The  Chest  Piece. — The  majority  of  the 

stethoscopes  now  in  use  have  a  chest  piece  of 

hard-rubber  or  wood  with  a  diameter  of  about  seven-eighths  of  an 

inch.     Chest  pieces  of  larger  diameter  than  this  are  to  be  avoided 

as  they  are  very  difficult  to  maintain  in  close  apposition  with  thin 


Fig.  49.  —  C  a  m  m  a  n 
Stethoscope  With  Stiff 
Tubing  and  Rubber 
Strap. 


Fig.  4.S.  —  stethoscope 
Fitted  With  Long 
Flexible  Tubes,  Espe- 
cially Useful  When 
Examining  Children. 


80       PHYSICAL  DIAGNOSIS   OF  DISEASES   OF  THE  CHEST. 


chests.     To  avoid  this  difficulty  the  chest  piece  is  sometimes  made 
of  soft-rubber  or  its  diameter  still  further  reduced. 

(6)  The  Bowles  Stethoscope. — (See  Figs.  50  aiid  51.)  Withia 
the  last  year  there  has  been  introduced  an  instrument  which,  for 
most  purposes,  seems  to  me  far  superior  to  any  other  form  of  stetho- 
scope with  which  I  am  acquainted.  Its  pe- 
culiarity is  the  chest  piece, 
which  consists  of  a  very  shal- 
low steel  cup  (see  Fig.  52) 
over  the  mouth  of  which  a 
thin  metal  plate  or  a  bit  of 
pigskin  is  fastened.  The 
metal  or  pigskin  diaphragm 
serves  simply  to  prevent  the 
tissues  of  the  chest  from  pro- 
jecting into  the  shallow  cup 
of  the  chest  piece  when  the 
latter  is  pressed  against  the 
chest,  and  does  not  in  any 
other  way  contribute  to  the 
sounds  which  we  hear  with 
the  instrimient.  This  is 
proved  by  the  fact  that  we 
can  hear  as  well  even  when 
the  diaphragm  is  cracked 
across  in  several  directions. 

"With  this  instrument  al- 
most all  sounds  produced 
within  the  chest  can  be  heard 
much  more  distinctly  than  in 
any  other  variety  of  stethoscope.  Cardiac  murmurs  which  are  in- 
audible with  any  other  stethoscope  maybe  distinctlyheardAviththis. 
Especially  is  this  true  of  low-pitched  murmurs  due  to  aortic  regur- 
gitation. Yet  it  is  useful  for  examination  not  merely  of  the  heart, 
but  of  the  lungs  as  well.  For  any  one  who  has  difficulty  in  hearing 
the  ordinary  cardiac  or  respiratory  sounds,  or  for  one  who  is  par- 


FiG.  50.— Bowles'   stetho- 
scope.   Front  view. 


Fig.  51.  —  Bowles' 
Stethoscope. 
Back  View. 


AUSCULTATION. 


81 


tially  deaf,  the  instrument  is  invaluable.  Its  flat  chest  piece  makes 
it  very  useful  in  listening  to  the  posterior  portions  of  the  lungs  in 
cases  of  pneumonia  in  which  the  patient  is  too  sick  to  be  turned  over 
or  to  sit  up.  Without  moving  the  patient  at  all  we  can  work  the 
chest  piece  ua  under  the  back  of  the  patient  by  pressing  down  the 
bed-clothes,  and  in  this  way  can  listen  to  any  part  of  the  chest 
without  moving  the  patient.  A  further  advantage  of  the  instru- 
ment is  that  it  enables  us  to  gain  an  approximately  accurate  idea 
of  the  heart  sounds  without  undressing  the  patient.     Respiratory 


Fig.  53.— Chest  Piece  of  Bowles'  Stethoscope.  On  the  right  the  shallow  cup  communicating 
with  the  ear  tubes.  On  the  left  the  diaphragm  which  covers  the  cup,  and  the  ring  which 
holds  It  In  place. 

soiinds  cannot  well  be  listened  to  through  the  clothes,  as  the  rub- 
bing of  the  latter  may  simulate  rales. 

There  are  two  purposes  for  which  I  have  foimd  the  Bowles 
stethoscope  inferior  to  the  ordinary  stethoscope : 

(1)  For  listening  over  the  apex  of  the  lung  for  fine  rales,  e.g.y 
in  incipient  phthisis. 

(2)  For  listening  for  superficial  sounds,  such  as  a  friction  rub 
of  a  presystolic  murmur.'     When  I  desire  to  listen  for  fine  rales  at 

'  It  has  frequently  been  observed,  when  listening  with  the  ordinary  stetho- 
scope, tliat  a  presystolic  murmur  can  be  lietter  heard  if  only  the  very  lightest 
pressure  is  made  with  the  stethoscope.  The  fact  that  a  thrill  is  communicated 
to  the  chest  wall,  and  that  that  thrill  is  connected  with  the  audible  murmur 
explains  my  calling  this  murmur  a  superficial  one. 

6 


82       PHYSICAL  DIAGAVSIS  OF  DISEASES  OF  THE  CHEST. 


an  apex,  for  a  friction  rub,  or  for  a  presystolic  murmur,  I  separate 
the  chest  piece  of  the  Bowles  stethoscope  from  the  rubber  tube  which 
connects  it  with  the  rest  of  the  instrument  and  slip  on  in  its  place 
the  hard-rubber  bell  of  an  ordinary  stethoscope,  thereby  converting 
the  instrument  into  one  of  the  ordinary  form.  With  an  extra  hard- 
_  rubber  bell  attached  or  kept 

in  the  pocket,  the  instrument 
is  no  more  bulky  than  an 
ordinary  stethoscope,  and 
far  more  efficient.  \^^len 
used  for  listening  to  the  res- 
piration, the  Bowles  instru- 
ment gives  us  information 
similar  in  some  respects  to 
that  obtained  by  the  use  of 
the  free  ear — that  is,  we  are 
through  it  enabled  to  ascer- 
tain by  listening  at  one  spot 
the  condition  of  a  much 
larger  area  of  the  chest  than 
can  in  any  other  way  be  in- 
vestigated. 

Owing  to  the  fact  that 
both  cardiac  and  respiratory 
sounds  are  magnified  by  the 
Bowles  stethoscope,  this 
instrument  is  especially  well 
adapted  for  use  with  some 
sort  of  an  attachment  whereby  several  sets  of  ear  pieces  are  so 
joined  by  tubing  to  one  chest  piece  that  several  persons  may  listen 
at  once.  Bowles'  multiple  stethoscope,  fitted  for  six  and  for  twelve 
observers,  is  seen  in  Figs.  53  and  54,  and  the  method  of  its  use  in 
Fig.  55.  In  the  teaching  of  auscultation  this  instrument  is  of  great 
value,  saving  as  it  does  the  time  of  the  instructor  and  of  the  stu- 
dents and  the  strength  of  the  patient.  The  sounds  conducted 
through  any  one  of  the  twelve  tubes  used  in  this  instrument  are 


Fig.  53.— Bowles'  Multiple  Stethoscope  for  Six  Stu- 
dents. 


AUSCULTATION. 


83 


as  loud  as  those  to  be  heard  with  a  single  instrument  of  the  ordi- 
nary form,  although  far  fainter  than  those  to  be  heard  with  a  single 
Bowles  stethoscope. 

II.    The  Use  of  the  Stethoscope. 
Having  secured  an  uistrument  which  fits  the  ears  satisfactorily, 
the  beginner  may  get  a  good  deal  of  practice  by  using  it  upon  him- 


FiG.  54.— Bowles'  Multiple  Stethoscope  for  Twelve  Students. 

self,  especially  upon  his  own  heart.  The  chief  point  to  be  learned 
is  to  disregard  various  irrelevant  soimds  and  to  concentrate  atten- 
tion upon  those  which  are  relevant.  Almost  any  one  hears  enough 
with  a  stethoscope,  and  most  beginners  hear  too  much.  No  great 
keenness  of  hearing  is  required,  for  the  sounds  which  we  listen  for 
are  not,  as  a  rule,  difficult  to  hear  if  attention  is  concentrated  upon 
them. 


84       PHYSICAL  DIAG^VSIS  OF  DISEASES  OF  THE  CHEST. 


A.   Selectice  Attention  and   What  to  Disrerjard. 

Accordingly,  the  art  of  using  a  stethoscope  successfully  depends 
upon  the  acquisition  of  two  powers — 

(«)  A  knowledge  of  what  to  disregard,      (/y)  A  selective  atten- 


Fi(i.  5o.— Biiwks"  Multiple  Stethoscope  in  Use.    Twelve  studeuts  listening  at  once 


tion  or  concentration  upon  those  sounds  which  we  know  to  be  of 
importance. 

Among  the  sounds  which  we  must  learn  to  disregard  are  the 
following : 

(1)  Noises  produced  in  the  room  or  its  immediate  neighborhood, 
but  not  connected  with  the  patient  himself.     It  is,  of  course,  easier 


AUSCULTATION.  85 

to  listen  in  a  perfectly  quiet  room  where  there  are  no  external 
noises  which  need  to  be  excluded  from  attention,  but  as  the  greater 
part  of  the  student's  work  must  be  done  in  more  or  less  noisy 
places,  it  is  for  the  beginner  a  practical  necessity  to  learn  to  with- 
draw his  attention  from  the  various  sounds  which  reach  his  ear 
from  the  street,  from  other  parts  of  the  building,  or  from  the  room 
in  which  he  is  working.  This  is  at  first  no  easy  matter,  but  can 
be  accomplished  with  practice. 

(2)  When  the  power  to  disregard  external  noises  has  been  ac- 
quired, a  still  further  selection  must  be  made  among  the  sounds 
which  come  to  the  ear  through  the  tubes  of  the  stethoscope.  Noises 
produced  by  friction  of  the  chest  piece  of  the  stethoscoi^e  upon  the 
skin  are  especially  deceptive  and  may  closely  simulate  a  pleural  or 
pericardial  friction  sound.  It  is  well  for  the  student  to  experiment 
upon  the  nature  and  extent  of  such  ''  skin  rubs  "  by  deliberately 
moving  the  chest  piece  of  the  stethoscope  upon  the  skin  and  listen- 
mg  to  the  sounds  so  produced.  Mistakes  can  be  avoided  in  the 
majority  of  cases  by  holding  the  chest  piece  of  the  stethoscope  very 
firmly  against  the  chest.  This  can  be  easily  done  when  the  patient 
is  m  the  recumbent  position,  but  when  the  patient  is  sitting  up  it 
may  be  necessary  to  press  so  hard  with  the  chest  piece  of  the 
stethoscope  as  to  throw  the  patient  off  his  balance  unless  he  is  in 
some  way  supported ;  accordingly,  it  is  my  practice  in  many  cases 
to  put  the  left  arm  around  and  behind  the  patient  so  as  to  form  a 
support,  against  which  he  can  lean  when  the  chest  piQce  of  the 
stethoscope  is  pressed  strongly  against  his  chest.  "VMien  listening 
to  the  back  of  the  chest,  the  manoeuvre  is  reversed.  If  the  skin 
is  very  dry,  the  ribs  are  very  prominent,  or  the  chest  is  thickly 
covered  with  hair,  it  may  be  impossible  to  prevent  the  occur- 
rence of  adventitious  sounds  due  to  friction  of  the  chest  piece 
upon  the  chest,  no  matter  how  firmly  the  instrument  is  held.  In 
case  of  doubt,  and  m  any  case  in  which  a  diagnosis  of  pleural  or 
pericardial  friction  is  in  question,  the  surface  of  the  chest,  at  the 
point  where  we  desire  to  listen,  should  be  moistened  and  any  hair 
that  may  be  present  thoroughly  wetted  with  a  sponge,  so  that  it 
will  lie  flat  upon  the  chest.     Otherwise  the  friction  of  the  hair 


86       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

under  the  chest  piece  of  the  stethoscope  may  simulate  crepitant 
r§,les  as  closely  as  "  skin  rubs  "  simulate  pleural  friction. 

(3)  The  friction  of  the  fingers  of  the  auscultator  upon  the  chest 
piece  or  on  some  other  part  of  the  stethoscope  frequently  gives  rise 
to  sounds  closely  resembling  rales  of  one  or  another  description. 
The  nature  of  these  sounds  can  be  easily  learned  by  intentionally 
moving  the  fingers  upon  the  stethoscope.  They  are  to  be  avoided 
by  gi'asping  the  instrument  as  firmly  as  possible,  and  by  touching  it 
with  as  few  fingers  as  will  suffice  to  hold  it  close  against  the  chest. 

(4)  Noises  produced  by  a  shifting  of  the  parts  of  the  stetho- 
scoj)e  upon  each  other  are  especially  frequent  in  stethoscopes  made 
in  several  pieces  and  jointed  together.  A  variety  of  snapping  and 
cracking  sounds,  not  at  all  unlike  certain  varieties  of  rales,  may 
thus  be  produced,  and  if  we  are  not  upon  our  guard,  may  lead  to 
errors  in  diagnosis.  Stethoscopes  which  have  no  hinges  and  which 
do  not  come  apart  are  far  less  likely  to  trouble  us  in  this  way. 

(5)  When  a  rubber  band  is  used  to  press  the  ear  pieces  more 
firmly  into  the  ears,  a  very  peculiar  sound  may  be  produced  by  the 
breathing  of  the  auscultator  as  it  strikes  upon  the  rubber  strap.  It 
is  a  loud  musical  note,  and  may  be  confused  with  coarse,  dry  rales. 

Wlien  one  has  learned  to  recognize  and  to  disregard  the  noises 
produced  in  the  ways  above  indicated,  there  is  still  one  set  of 
sounds  which  are  very  frequently  heard,  yet  which  have  no  signifi- 
cance for  physical  diagnosis,  and  must  therefore  be  disregarded ;  I 
refer  to 

B.    Muscle  Sounds. 

Patients  who  hold  themselves  very  erect  while  being  exam- 
ined, or  who  for  any  reason  contract  the  muscles  of  that  portion  of 
the  chest  over  which  we  are  listening,  produce  in  these  muscles  a 
very  peculiar  and  characteristic  set  of  sounds.  The  contraction  of 
any  muscle  in  the  body  produces  sounds  similar  in  quality  to  those 
heard  over  the  chest,  but  of  less  intensity. 

Those  who  have  the  faculty  of  contracting  the  tensor  tympani 
muscle  at  will  can  at  any  time  listen  to  a  typical  muscle  sound. 


A  use ULTA TION.  87 

Or  close  both  ears  with  the  fingers  and  strongly  contract  the  mas- 
seter  mnscle,  with  the  teeth  clenched.  A  high-pitched  muscle 
sound  will  be  heard. 

It  is  well  also  to  have  a  patient  contract  one  of  the  pectorals 
and  then  listen  to  the  sound  thus  produced.  In  some  cases  a  con- 
tinuous, low-pitched  roar  or  drumming  is  all  that  we  hear ;  in  other 
cases  we  hear  nothing  but  the  breath  soimds  during  expiration, 
while  during  inspiration  the  breath  sound  is  obscured  by  a  series  of 
short,  dull,  rumbling  sounds,  following  each  other  at  the  rate  of 
from  five  to  ten  in  a  second.  Occasionally  the  sound  is  like  the 
pufiing  of  the  engine  attached  to  a  pile-driver,  or  like  a  stream  of 
water  falling  upon  a  sheet  of  metal  just  slowly  enough  to  be  sepa- 
rated into  drops  and  heard  at  a  considerable  distance.  As  already 
mentioned,  we  are  especially  apt  to  hear  these  muscle  sounds  dur- 
ing forced  inspiration,  owing  to  the  contraction  of  voluntary  mus- 
cles during  that  portion  of  the  respiratory  act.  They  are  most 
often  heard  over  the  upper  portion  of  the  chest  (over  the  pectorals 
in  front  and  over  the  trapezius  behind),  but  m  some  persons  no 
part  of  the  chest  is  free  from  them.  It  is  a  curious  fact  that  we 
are  not  always  able  to  detect  by  sight  or  touch  the  muscular  con- 
tractions which  give  rise  to  these  sounds,  and  the  patient  himself 
may  be  wholly  unaware  of  them.  Under  such  circumstances  they 
are  not  infrequently  mistaken  for  rSles,  and  I  am  inclined  to  think 
that  many  of  the  sounds  recorded  as  ** crumpling,"  "obscure," 
"muffled,"  "distant,"  or  "indeterminate"  r§,les  are  in  reality  due 
to  muscular  contractions.  The  adjectives  "  muffled  "  and  "  distant " 
give  us  an  inkling  as  to  the  qualities  which  distinguish  muscular 
sounds  from  rales.  Rales  are  more  clean  cut,  have  a  more  distinct 
beginning  and  end,  seem  nearer  to  the  ear,  and  possess  more  of  a 
crackling  or  bubbling  quality  than  muscle  sounds. 

I  have  made  no  attempt  exhaustively  to  describe  all  the  sounds 
due  to  muscular  contractions  and  conducted  to  the  ear  by  the  steth- 
oscope, but  have  intended  simply  to  call  attention  to  the  importance 
of  studymg  them  carefully. 


88       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 


C.    Other  Sources  of  Error. 

Another  source  of  confusion,  which  for  beginners  is  very  trouble- 
some, especially  if  they  are  using  the  ordinary  form  of  stethoscope 
■with  a  bell-shaped  chest  piece,  arises  in  case  the  chest  piece  is  not 


Fig.  otj.— Showing  an  Accident  to  be  Avoided.     (Stethosr. 


.liwted.) 


held  perfectly  in  apposition  with  the  skin.  If,  for  example,  the 
stethoscope  is  slightly  tilted  to  one  side  so  that  the  bell  is  lifted 
from  the  skin  at  some  point,  or  if  one  endeavors  to  listen  ovef 
a  very  uneven  part  of  the  chest  on  which  the  bell  of  the  stethoscope 
cannot  be  made  to  rest  closely,  a  roar  of  external  noises  reaches  the 
ear  through  the  chink  left  between  the  chest  piece  and  the  chest. 


AUSCULTATION.  89 

After  a  little  practice  one  learns  instantlj-  to  detect  this  condition 
of  things  and  so  to  shift  the  position  of  the  chest  piece  that  exter- 
nal noises  are  totally  excluded ;  but  by  the  beginner,  the  peculiar 
babel  of  external  noises  which  is  heard  whenever  the  stethoscope 
fails  to  fit  closely  against  the  chest  is  not  easily  recognized,  and 


Fig.  57.— Accident  to  be  Avoided.    CStetboscope  Idnked.) 

hence  he  tends  to  attribute  some  of  these  external  sounds  to  diseased 
conditions  within  the  chest. 

Again,  it  is  not  until  we  have  had  considerable  practice  that  our 
sense  of  hearing  comes  instantly  to  tell  us  when  something  is  wrong 
about  the  stethoscope  itself ;  when,  for  example,  one  of  the  tubes 
is  blocked,  kinked,  or  disconnected  (see  Figs.  56  and  57),  or  when 
we  are  holding  the  stethoscope  upside  down,  so  that  the  ear  pieces 
point  downward  instead  of  upward  (see  Figs.  58  and  59).  It  is  only 
when  we  have  learned  through  long  practice  about  how  much  we 


90       PHYSICAL  DIAG^'OSIS  OF  DISEASES  OF  THE  CHEST. 

ought  to  hear  at  a  given  point  in  the  normal  chest  that  we  recognize 
at  once  the  fact  that  we  are  not  hearing  as  much  as  we  should,  in 


Fig.  58.— stethoscope  Held  Right  Side  Up. 


case  some  one  of  the  above  accidents  has  happened.  Many  begin- 
ners do  not  listen  long  enough  in  any  one  place,  but  move  the  chest 
piece  of  the  stethoscope  about  rapidly  from  point  to  point,  as  they 
have  seen  experienced  auscultators  do;  but  it  is  remarkable  how 
much  more  one  can  hear  at  a  given  point  by  simply  persevering  and 
listening  to  beat  after  beat,  or  breath  after  breath.     It  is  sometimes 


Fig.  59.— stethoscope  Held  Wrong  Side  Up. 


difficult  to  avoid  the  impression  that  the  sounds  themselves  have 
grown  louder  as  we  continue  to  listen,  especially  if  we  are  in  any 


AUSCULTATION.  91 

doubt  as  to  what  we  hear.  Therefore,  if  we  hear  indistinctly,  it  is 
important  to  keep  on  listening,  and  to  fix  the  attention  successively 
upon  each  of  the  different  elements  in  the  sounds  under  consideration. 
In  difficult  cases  we  should  use  every  possible  aid  toward  concen- 
tration of  the  attention,  and  where  it  is  possible,  all  sources  of  dis- 
traction should  be  eliminated.  Thus,  in  any  case  of  doubt,  I  think 
it  is  important  for  the  auscultator  to  get  himself  into  as  comfort- 
able a  position  as  he  can,  so  that  his  attention  is  not  distracted  by 
his  own  physical  discomforts.  Many  auscultators  shut  their  eyes 
when  listening  in  a  difficult  case  so  as  to  avoid  the  distraction  of 
impressions  coming  through  the  sense  of  sight.  It  goes  without 
saying  that  if  quiet  can  be  secured  in  the  room  where  we  are  work- 
ing, and  outside  it  as  well,  we  shall  be  enabled  to  listen  much  more 
profitably. 

AUSCULTATION  OF  THE  LUNGS. 

In  the  majority  of  cases  ordinary  quiet  breathing  is  not  forcible 
enough  to  bring  out  the  sounds  on  which  we  depend  for  the  diag- 
nosis of  the  condition  of  the  lungs.  Deep  or  forced  breathing  is 
what  we  need. 

As  a  rule,  the  patient  must  be  taught  how  to  breathe  deeply, 
which  is  best  accomplished  by  personally  demonstrating  the  act  of 
deep  breathing  and  then  asking  him  to  do  the  same.  Two  difficul- 
ties are  encountered : 

{a)  The  patient  may  blow  out  his  breath  forcibly  and  with  a 
noise,  since  that  is  what  he  is  used  to  doing  whenever  he  takes  a 
long  breath  under  ordinary  circumstances ;  or 

(h)  It  may  be  that  he  cannot  be  made  to  take  a  deep  breath  at 
all.  The  first  of  these  mistakes  alters  the  sounds  to  be  heard  with 
the  stethoscope  in  any  part  of  the  chest  by  disturbing  both  the 
rhythm  and  the  pitch  of  the  respiratory  sounds.  In  this  way  the 
breathing  may  be  made  to  sound  tubular  or  asthmatic  throughout  a 
sound  chest.  This  difficulty  can  sometimes  be  overcome  by  demon- 
strating to  the  patient  that  what  you  desire  is  to  have  him  take  a 
full  breath  and  then  simply  let  it  go,  but  not  blow  it  forcibly  out. 
In  some  cases  the  patient  cannot  be  taught  this,  and  we  have  to  get 


92       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

on  the  best  we  cau  despite  his  mistakes.  AMien  he  cannot  be  made 
to  take  a  full  breath  at  all,  we  can  often  accomplish  the  desired  re- 
sult by  getting  him  to  cough.  The  breath  just  before  and  after  a 
cough  is  often  of  the  type  Ave  desire.  The  use  of  voluntary  cough 
in  order  to  bring  out  rales  will  be  discussed  later  on.  Another  use- 
ful manoeuvre  is  to  make  the  patient  count  aloud  as  long  as  he  can 
with  a  single  breath.  The  deep  inspiration  which  he  is  forced  to 
take  after  this  task  is  of  the  type  which  we  desire. 

I.  Eespikatory  Types. 

In  the  normal  chest  two  types  of  breathing  are  to  be  heard : 

(1)  Tracheal,  bronchial,  or  tubular  breathing. 

(2)  Vesicular  breathing. 

Tracheal,  bronchial,  or  tubular  breathing  is  to  be  heard  in  normal 
cases  if  the  stethoscope  is  pressed  against  the  trachea,  and  as  a  rule 


Fig.  60.— situation  of  the  Trachea  and  Primary  Bronchi. 


it  can  also  be  heard  over  the  situation  of  the  primary  bronchi,  in 
front  or  behind  (see  Figs.  60  and  61) . 

Vesiailar  breathing  is  to  be  heard  over  the  remaining  portions  of 
the  lung — that  is,  in  the  front  of  the  thorax  except  where  the  heart 


AUSCULTATION. 


93 


and  the  liver  come  against  the  chest  wall,  in  the  back  except  where 
the  presence  of  the  sca|)ulae  obscures  it,  and  throughout  both  axillae. 

(1)  Characteristics  of  Vesicular  Breathing. 

Vesicular  breathing — that  heard  over  the  air  vesicles  or  paren- 
chyma of  the  lung — has  certain  characteristics  which  I  shall  try  to 
describe  in  terms  of  intensity,  duration,  and  pitch. 


Fig.  61.— Situation  of  the  Trachea  and  Primary  Bronchi. 

Of  the  quality  of  the  sounds  heard  over  this  portion  of  the  lung 
there  is  little  can  be  said ;  it  sounds  something  like  the  swish  of  the 
wind  in  a  grove  of  trees  some  distance  off,  and  hence  is  sometimes 
spoken  of  as  "breezy." 

The  intensity,  duration,  and  pitch  of  the  inspiration  as  compared 
with  that  of  the  expiration  may  be  represented  as  in  Fig.  62.  In 
this  figure,  as  in  all  those  to  be  used  in  description  of  respiratory 
sounds — 

(1)  I  represent  the  inspiration  by  an  up-stroke  and  the  expira- 
tion by  a  down-stroke  (see  the  direction  of  the  arrows  in  Fig.  62). 

(2)  The  length  of  the  up-stroke  as  compared  with  that  of  the 
down-stroke  corresponds  to  the  length  of  inspiration  compared  with 
expiration. 


94       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

(3)  The  thickness  of  the  iip-stroke  as  compared  with  the  down- 
stroke  represents  the  inteitsity  of  the  inspiration  as  compared  with 
the  expiration. 

(4)  The  lyitch  of  inspiration  as  compared  with  that  of  expi- 
ation is  represented  by  the  sJunyness  of  the  angle  which  the  up- 


FlG.  62. 


-Vesicular  Breatb- 
ing. 


Fig.  63.— Distant  Vesicular 
Breathing. 


Fig.   64. -Exaggerated  Ve- 
sicular Breathing. 


stroke  makes  with  the  perpendicular  as  compared  with  that  which 
the  down-stroke  makes  with  the  perpendicular.  The  lAtch  of  a 
roffmsij  be  thought  of  m  this  connection  to  remind  us  of  the  mean- 
ing of  these  symbols. 

If  now  we  look  again  at  Fig.  62  we  see  that  when  compared 
with  expiration  (the  down-stroke),  the  inspiration  is — 

(«)  More  intense. 

(b)  Longer. 

(c)  Higher  pitched. 

Our  comparison  is  invariably  made  between  inspiration  and  ex- 
piration, and  not  with  any  other  sound  as  a  standard. 

Now,  this  type  of  breathing  (which,  as  I  have  said,  is  to  be 
heard  over  every  portion  of  the  lung  except  those  portions  imme- 
diately adjacent  to  the  primary  bronchi),  is  not  heard  everywhere 
with  equal  intensity.  It  is  best  heard  below  the  clavicles  in  front, 
in  the  axillae,  and  below  the  scapulae  behind,  but  over  the  thin, 
lower  edges  of  the  lung,  whether  behind  or  at  the  sides,  it  is 
feebler,  though  still  retaining  its  characteristic  type  as  revealed  in 
the  inspiration  and  expiration  in  respect  to  intensity,  duration,  and 
pitch.  To  represent  distant  A^esicular  breathing  graphically  Ave 
have  only  to  draw  its  symbol  on  a  smaller  scale  (see  Fig.  63).     On 


AUSCULTATION. 


95 


the  other  hand,  when  one  listens  to  the  lungs  of  a  person  who  has 
been  exerting  himself  strongly,  one  hears  the  same  type  of  respira- 
tion, but  on  a  larrjer  scale,  which  may  then  be  represented  as  in 
Fig.  64.  This  last  symbol  may  also  be  used  to  represent  the  respi- 
ration which  we  hear  over  normal  but  thin-walled  chests ;  for  ex- 
ample, in  children  or  in  emaciated  persons.  It  is  sometimes  known 
as  "  exaggerated "  or  "  puerile  "  respiration.  When  one  lung  is 
thrown  out  of  use  by  disease  so  that  increased  work  is  brought 
upon  the  other,  the  breath  sounds  heard  over  the  latter  are  increased 
and  seem  to  be  produced  on  a  larger  scale.  Such  breathing  is  some- 
times spoken  of  as  "  rough  "  breathing. 

It  is  very  important  to  distinguish  at  the  outset  between  the 
different  tijjies  of  breathing,  one  of  which  I  have  just  described,  and 
the  different  degrees  of  Toudness  with  which  any  one  type  of  breath- 
ing may  be  heard. 

(2)  Bronchial  or  Tracheal  Breathing  in  Health. 

Bronchial  breathing  may  be  symbolically  represented  as  in  Fig. 
65,  in  which  the  increased  length  of  the  down  stroke  corresponds 
to  the  increased  duration  of  expiration,  and  the  greater  thickness 


Fig.  65. —Bronchial  Breath- 
ing of  Moderate  Intensity. 


Fig.  66.— Distant  Bronchial 
Breathing. 


Fig.  67.— Very  Loud  Bron- 
chial Breathing. 


of  both  lines  corresponds  to  the  greater  intensity  of  both  sounds, 
expiratory  and  inspiratory,  while  the  sharp  pitch  of  the  "  gable  "  on 
both  sides  of  the  perpendicular  corresponds  to  the  high  pitch  of 
both  sounds.  Expiration,  it  will  be  noticed,  slightly  exceeds  inspi- 
ration both  in  intensity  and  pitch,  and  considerably  exceeds  it  in 
duration,  while  as  compared  with  vesicular  breathing  almost  all  the 


96       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

relations  are  reversed.  Bronchial  breathing  has  also  a  peculiar 
quality  which  can  be  better  appreciated  than  described. 

In  the  healthy  chest  this  type  of  breathing  is  to  be  heard  if  one 
listens  over  the  trachea  or  primary  bronchi  (see  above,  Fig.  60), 
but  practically  one  hai'dly  ever  listens  over  the  trachea  and  bronchi 
except  by  mistake,  and  the  importance  of  familiarizing  one's  self 
with  the  type  of  respiration  heard  over  these  portions  of  the  chest 
is  due  to  the  fact  that  in  certain  diseases,  especially  in  pneumonia 
and  phthisis,  we  may  hear  bronchial  breathing  over  the  parenchyma 
of  the  lung  where  normally  vesicular  breathing  should  be  heard. 

The  student  should  familiarize  himself  with  each  of  these  types 
of  breathing,  the  vesicular  and  the  bronchial,  concentrating  his  at- 
tention as  he  listens  first  upon  the  inspiration  and  then  upon  the 
expiration,  and  comparing  them  with  each  other,  first  in  duration, 
next  in  intensity,  and  lastly  in  pitch.  To  those  Avho  have  not  a 
musical  ear,  high-pitched  sounds  convey  the  general  imjiression  of 
being  shrill,  while  low-pitched  sounds  sound  hollow  and  empty,  but 
the  distinction  between  intensity  and  pitch  is  one  comparatively 
difficult  to  master.  Distant  bronchial  breathing  may  be  repre- 
sented in  Fig.  66,  and  is  to  be  heard  over  the  back  of  the  neck 
opposite  the  position  of  the  trachea  and  bronchi.  Fig.  67  repre- 
sents very  loud  bronchial  breathing  such  as  is  sometimes  heard  in 
pneumonia. 

(3)  Broncho-  Vesicular  Breathing  in  Health. 

As  indicated  by  its  name,  this  type  of  breathing  is  intermediate 
between  the  two  just  described,  hence  the  terms  "  mixed  breath- 
ing," or  "at3q)ical  breathing  "  ("unbestimmt ").  Its  characteristics 
may  be  symbolized  as  in  Fig.  68.  In  the  normal  chest  one  can  be- 
come familiar  with  broncho-vesicular  breathing,  by  examining  the 
apex  of  the  right  lung,  or  by  listening  over  the  trachea  or  one  of  the 
primary  bronchi,  and  then  moving  the  stethoscope  half  an  inch  at 
a  time  toward  one  of  the  nipples.  In  the  course  of  this  journey 
one  passes  over  points  at  which  the  breathing  has,  in  varying  de- 
grees, the  characteristics  intermediate  between  the  bronchial  type 
from  which  we  started  and  the  vesicular  type  toward  which  we  are 


AUSCULTATION. 


97 


moving.     Expiration  is  a  little  longer,  intenser,  or  higher  pitched 
than  in  vesicular  breathing,  and  mspiration  a  little  shorter,  feebler, 


/h 


r 


Fig.  68.— Two  Common  Types  of  Broncho- 
Vesicular  Breathing. 


Fig.   69.— Distant  Broncho-Vesicular  Breath- 
ing. 


or  lower  pitched ;  but  since  these  characteristics  are  variously  com- 
bined, there  are  many  subvarieties  of  broncho-vesicular  breathing. 
Fig.  69  represents  two  types  of  distant  broncho-vesicular  breath- 
ing. 

(4)  Emphysematous  Breathing. 

A  glance  at  Fig.  70  will  call  up  the  most  important  features  of 
this  type  of  respiration.  The  mspiration  is  short  and  somewhat 
feeble,  but  not  otherwise  remarkable.  The  expiration  is  long, 
feeble,  and  low  pitched.  This  type  of  breathing  is  the  rule  in 
elderly  persons,  particularly  those  of  the  male  sex. 

(o)  Asthmatic  Breathhuj. 

Fig.  71  differs  from  emphysematous  only  in  the  greater  intensity 
of  the  expiration.     In  this  type  of  breathing,  however,  both  sounds 


Fig.  70.— Emphysematous  Breathing. 


Fig.    71.  —  Asthmatic    Breathing, 
squeaking  (musical)  rales. 


are  usually  obscured  to  a  great  extent  by  the  presence  of  piping  and 
squeaking  rSles  (see  below) . 
7 


98       PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

(6)  Infeniqjted  or  "  Cogivheel  "  Breathing. 

As  a  rule,  only  the  insisiration  is  interrupted,  being  transformed 
into  a  series  of  short,  jerky  puffs  as  shown  in  Fig.  72.  Very  rarely 
the  expiration  is  also  divided  into  segments.  When  heard  over  the 
entire  chest,  cogwheel  breathing  is  usually  the  result  of  nervous- 
ness, fatigue,  or  chilliness  on  the  patient's  part.  "With  the  removal 
of  these  causes  this  type  of  respiration  then  disappears.  If,  on  the 
other  hand,  cogwheel  respiration  is  confined  to  a  relatively  small 
portion  of  the  chest,  and  remains  present  despite  the  exclusion  of 


/ 


x?'T^  /> 


Fig.  72.— Cogwheel  Breathing.  Fig.  73.— Metamorphosing  Breathing. 

fatigue,  nervousness,  or  cold,  it  points  to  a  local  catarrh  in  the  finer 
bronchi  such  as  to  render  difficult  the  entrance  of  air  into  the  alve- 
oli. As  such,  it  has  a  certain  significance  in  the  diagnosis  of  early 
phthisis,  a  significance  similar  to  that  of  rales  or  other  signs  of 
localized  bronchitis  (see  below) . 

(7)  Amjihoric  or  Cavernous  Breathing  (see  below,  p.  103). 

(8)  Metamorphosing  Breathing. 

Occasionally,  while  we  are  listening  to  an  inspiration  of  normal 
pitch,  intensity,  and  quality,  a  sudden  metamorphosis  occurs  and  the 
type  of  breathing  changes  from  vesicular  to  bronchial  or  amphoric 
(see  Fig.  73),  or  the  intensity  of  the  breath  sounds  may  suddenly 
be  increased  without  other  change.  These  metamorphoses  are  usu- 
ally owing  to  the  fact  that  a  plugged  bronchus  is  suddenly  opened 
by  the  force  of  the  inspired  air,  so  that  the  sounds  conducted 
through  it  become  audible. 


AUSCULTATION.  99 

II.  Differences  between  the  Two  Sides  of  the  Chest. 

Over  the  apex  of  the  right  lung — that  is,  above  the  right  clavi- 
cle in  front,  and  above  the  spine  of  the  scapula  behind — one  liears 
in  the  great  majority  of  normal  chests  a  distinctly  broncho- vesicu- 
lar type  of  breathing.  In  a  smaller  number  of  cases  this  same 
type  of  breathing  may  be  heard  just  below  the  right  clavicle. 
These  facts  cannot  be  too  strongly  insisted  upon,  since  it  is  only 
by  bearing  them  in  mind  that  we  can  avoid  the  mistake  of  diagnos- 
ing a  beginning  consolidation  of  the  right  apex  where  none  exists. 
Breath  sounds  which  are  perfectly  normal  over  the  right  apex  would 
mean  serious  disease  if  heard  over  similar  p}ortions  of  the  left  lung. 
It  will  be  remembered  that  the  apex  of  the  right  lung  is  also  duller 
on  percussion  than  the  corresponding  portion  of  the  left,  and  that 
the  voice  sounds  and  tactile  fremitus  are  normally  more  intense  on 
the  right  (see  Fig.  32). 

Occasionally  one  finds  at  the  base  of  the  right  lung  posteriorly 
a  slightly  feebler  or  more  broncho-vesicular  type  of  breathing  than 
in  the  corresponding  portion  of  the  left  lung. 

III.  Pathological  Modifications  of  Vesicular  Breathing. 

Having  now  distinguished  the  dilferent  types  of  breathing  and 
described  their  distribution  in  the  normal  chest,  we  must  return  to 
the  normal  or  vesicular  breathing  in  order  to  enumerate  certain  of 
its  modifications  which  are  important  in  diagnosis. 

(1)  Exaggerated  Vesicular  Breathing  ("  Compensatory  "  Breathing). 

(a)  It  has  already  been  mentioned  that  in  children  or  m  adults 
with  very  thin  and  flexible  chests  the  normal  breath  sounds  are 
heard  with  relatively  great  distinctness ;  also  that  after  any  exer- 
tion which  leads  to  abnormally  deep  and  forcible  breathing  a  simi- 
lar increase  in  the  intensity  of  the  respiratory  sounds  naturally 
occurs. 

(b)  The  term  "  compensatory  breathing,"  or  "  vicarious  "  breath- 
ing, refers  to  vesicular  breathing  of  an  exaggerated  type,  such  as  is 
heard,  for  example,  over  the  whole  of  one  lung  when  the  other  lung 


100    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

is  thrown  out  of  use  by  the  pressure  of  an  accumulation  of  air  or 
fluid  in  the  pleural  cavity.  A  similar  exaggeration  of  the  breathing 
upon  the  sound  side  takes  place  when  the  other  lung  is  solidified, 
as  by  tuberculosis,  pneumonia,  or  malignant  disease,  or  when  it  is 
compressed  by  the  adhesions  following  pleuritic  effusion,  or  by 
a  contraction  of  the  bones  of  that  side  of  the  chest  such  as  occurs 
in  spinal  curvature. 

(2)  Diminished  Vesicular  Breathing. 

The  causes  of  a  diminution  in  the  intensity  of  the  breath  sounds 
without  any  change  in  their  type  are  very  numerous.  I  shall  men- 
tion them  in  an  order  corresponding  as  nearly  as  possible  to  the 
relative  frequency  of  their  occurrence. 

(a)  Fluid,  Air,  or  Solid  in  the  Pleural  Cavity. — Probably  the 
commonest  cause  for  a  diminution  or  total  abolition  of  normal 
breath  sounds  is  an  accumulation  of  fluid  in.  the  pleural  cavity  such 
as  occurs  in  inflammation  of  the  pleura  or  by  transudation  (hydro- 
thorax).  In  such  cases  the  layer  of  fluid  intervening  between  the 
lung  and  the  stethoscope  of  the  auscultator  causes  retraction  of  the 
lung  so  that  little  or  no  vesicular  murmur  is  produced  in  it,  and 
hence  none  is  transmitted  to  the  ear  of  the  auscultator.  An  ac- 
cumulation of  air  in  the  pleural  cavity  (pneiimothorax)  may  dimin- 
ish or  abolish  the  breath  sounds  precisely  as  a  layer  of  fluid  does ; 
in  a  somewhat  different  way  a  thickening  of  the  costal  or  pulmo- 
nary pleura  or  a  malignant  groAvth  of  the  chest  wall  may  render 
the  breath  sounds  feeble  or  prevent  their  being  heard  because  the 
vibrations  of  the  thoracic  sounding-board  are  thus  deadened.  Which- 
ever of  these  causes,  fluid  or  air  or  solid,  intervenes  between  the  lung 
and  the  ear  of  the  auscultator,  the  breath  sounds  are  deadened  or 
diminished  without,  as  a  rule,  any  modification  of  their  type.  The 
amount  of  such  diminution  depends  roughly  on  the  thickness  of  the 
layer  of  extraneous  substance,  whether  fluid,  air,  or  solid. 

Total  absence  of  breath  sounds  may  therefore  be  due  to  any  one 
of  these  causes,  provided  the  layer  intervening  between  the  lung  and 
chest  wall  is  of  sufficient  thickness  to  produce  complete  atelectasis 
of  the  lung  or  to  deaden  the  vibrations  of  the  chest  wall. 


AUSCULTATION.  101 

(b)  Emjjhijsema  of  the  hnig,  by  destrojring  its  elasticity  and  re- 
ducing the  extent  of  its  movements,  makes  the  breath  sounds  rela- 
tively feeble,  but  seldom,  if  ever,  abolishes  them  altogether. 

(c)  In  bronchitis  the  breath  sounds  are  usually  considerably  di- 
minished owing  to  the  filling  up  of  the  bronchi  with  seci-etion. 
This  diminution,  however,  usually  attracts  but  little  attention, 
owing  to  the  fact  that  the  bubbling  and  squeaking  sounds,  which 
result  from  the  passage  of  air  through  the  bronchial  secretions,  dis- 
tract our  notice  to  such  an  extent  that  we  find  it  tliflScult  to  con- 
centrate attention  upon  the  breath  sounds,  even  if  we  do  not  forget 
altogether  to  listen  to  them.  When,  however,  we  succeed  in  listen- 
ing through  the  rules  to  the  breath  sounds  themselves,  we  usually 
notice  that  they  are  very  feeble,  especially  over  the  lower  two- 
thirds  of  the  chest.  (Edema  of  the  lung  may  diminish  the  breath 
sounds  in  a  similar  way. 

(d)  Poiu  in  the  thorax j  such  as  is  produced  by  dry  pleurisy  or 
intercostal  neuralgia,  diminishes  the  breath  soimds  because  it  leads 
t^e  patient  to  restrain,  so  far  as  possible,  the  movements  of  his 
chest,  and  so  of  his  lungs.  If,  for  any  other  reason,  the  full  ex- 
pansion of  the  lung  does  not  take  place,  whether  on  account  of  the 
feebleness  of  the  respiratory  movements  or  because  the  lung  is  me- 
chanically hindered  by  the  presence  of  pleuritic  adhesions,  the 
breath  sounds  are  proportionately  feeble. 

(e)  Occlusion  of  the  upper  air  possagesj  as  by  spasm  or  oedema 
of  the  glottis,  renders  the  breathing  very  feeble  on  both  sides  of 
the  chest.  If  one  of  the  primary  bronchi  is  occluded,  as  by  a  for- 
eign body  or  by  pressure  of  a  tumor  or  enlarged  gland  from  without, 
we  get  a  imilateral  enfeeblement  of  the  breathing  over  the  corre- 
sponding lung. 

(/)  Occasionally  a  paralysis  of  the  muscles  of  respiration  on  one 
or  both  sides  is  found  to  result  in  a  unilateral  or  bilateral  enfeeble- 
ment of  the  breathing. 

It  should  be  remembered,  when  estimating  the  intensity  of  the 
breathing,  that  the  sounds  heard  over  the  right  lung  are,  as  a  rule, 
slightly  more  feeble  than  those  heard  over  the  left  lung  in  the 
normal  chest. 


102     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 


IV.  Bronchial  or  Tubular  Breathing  in  Disease. 

(a)  I  have  already  described  the  occurrence  of  bronchial  breath- 
ing in  parts  of  the  normal  chest,  namely,  over  the  trachea  and  jjri- 
mary  bronchi.  In  disease,  bronchial  breathing  may  be  heard  else- 
where in  the  chest,  and  usually  points  to  solidification  of  that  portion 
of  lung  from  which  it  is  conducted.  It  is  heard  most  commonly  in 
phthisis  (see  below,  p.  249). 

(b)  CroHjwHs  jmenmonia  is  probably  the  next  most  frequent 
cause  of  bronchial  breathing,  although  by  no  means  every  case  of 
croupous  pneumonia  shows  this  sign.  For  a  more  detailed  account 
of  the  conditions  under  which  it  does  or  does  not  occur  in  croupous 
pneumonia,  see  below,  p  239.  Lobular  pneumonia  is  rarely  mani- 
fested by  tubular  breathing. 

(e)  In  about  one-third  of  the  cases  of  pleuritic  effusion  distant 
bronchial  breathing  is  to  be  heard  over  the  fluid.  On  account  of 
the  feebleness  of  the  breath  sounds  in  such  cases  they  are  often 
jjut  down  as  absent,  as  we  are  so  accustomed  to  associate  intensity 
with  the  bronchial  type  of  breathing.  One  should  be  always  on 
the  watch  for  any  degree  of  intensity  of  bronchial  breathing  from 
the  feeblest  to  the  most  distinct. 

{(T)  Barer  causes  of  bronchial  breathing  are  hemorrhagic  infarc- 
tion of  the  lung,  syphilis,  or  malignant  disease,  any  one  of  which 
may  cause  a  solidification  of  a  portion  of  the  lung. 

V.    BROXCHO-A^E;iICULAR    BrEATHIXG    IX    DiSEASE. 

Respiration  of  this  type  should  be  carefully  distinguished  from 
puerile  or  exaggerated  breathing,  in  which  we  hear  the  normal  vesic- 
ular respiration  upon  a  large  scale.  I  have  already  mentioned 
that  broncho-vesicular  breathing  is  normally  to  be  heard  over  the 
apex  of  the  right  lung.  In  disease,  broncho-vesicular  breathing  is 
heard  in  other  portions  of  the  lung,  and  usually  denotes  a  moderate 
degree  of  solidification  of  the  lung,  such  as  occurs  in  early  phthisis 
or  in  the  earliest  and  latest  stages  of  croupous  pneumonia.  In  cases 
of  pleuritic  effusion,  one  can  usually  hear  broncho-vesicular  breath- 


A  use  UL  TA  TION.  103 

ing  over  the  upper  portion  of  the  aifected  side,  owing  to  the  retrac- 
tion of  the  hmg  at  that  point. 

VI.  Amphoric  Breathing  [Amphora  =  A  Jar). 

Respirations  having  a  hollow,  empty  sound  like  that  produced 
by  blowing  across  the  top  of  a  bottle,  are  occasionally  heard  in  dis- 
ease over  pulmonary  cavities  {e.(/.,  in  phthisis)  or  in  pneumothorax, 
i.e.,  under  conditions  in  which  the  air  passes  in  and  out  of  a  large 
empty  cavity  within  the  chest.  Amphoric  breathing  never  occurs 
in  health.  The  pitch  of  both  sounds  is  low,  but  that  of  expiration 
lower  than  that  of  inspiration.  The  intensity  and  duration  of  the 
sounds  vary,  and  the  distinguishing  mark  is  their  quality  which 
resembles  that  of  a  whispered  ^'i/.-Ao." 

VII.  Rales. 

The  term  "  rales  "  is  applied  to  sounds  produced  by  the  passage 
of  air  through  bronchi  which  contain  mucus  or  pus,  or  which  are 
narrowed  by  swelling  of  their  walls. '  Rales  are  best  classified  as 
follows : 

(1)  Moist  or  bubbling  rales,  including  («)  coarse,  {h)  medium, 
and  (c)  fine  rales. 

(2)  Dry  or  crackling  r§,les  (large,  medium,  or  fine) . 

The  smallest  varieties  of  this  type  are  known  as  "  crepitant "  or 
"  subcrepitant "  rales. 

(3)  ]\[usical  rales  (high  or  low  pitched). 

Each  of  these  varieties  will  now  be  described  more  in  detail. 

(1)  Hoist  or  Bubbling  Rales. 

The  nature  of  these  is  sufficiently  indicated  by  their  name. 
The  coarsest  or  largest  bubbles  are  those  produced  in  the  trachea, 
and  ordinarily  known  as  the  ^^ death  rattle.^'     Tracheal  rales  occur 

'  Rales  are  of  all  auscultatory  phenomena  the  easiest  to  appreciate,  pro- 
vided we  exclude  various  accidental  sounds  which  may  be  transmitted  to  the 
ear  as  a  result  of  friction  of  the  stethoscope  against  the  skin  or  against  the 
fingers  of  the  observer.     (See  above,  page  86.) 


104    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

in  any  condition  involving  either  profound  unconsciousness  or  very 

great  weakness,   so  that  the  secretions  Avhich   accumulate  in  the 

trachea  are  not  coughed  out.      Tracheal  rales  are  by  no  means  a 

sure  precursor  of  death,  although  they  are  very  common  in  the 

moribund  state.     They  can  usually  be  heard  at  some  distance  from 

the  patient  and  without  a  stethoscope.     In  catarrh  of  the  larger 

bronchi   large  bubbling   rales   are  occasionally  to  l^e 

heard.      In   phthisical   cavities  one    sometimes   hears 

coarse,  bubbling  rtles  of  a  very  metallic  and  gurgling 

quality  (see  below,  p.  252).     The  finer  grades  of  moist 

i  r^les  correspond  to  the  finer  bronchi. 

•    I  In  the  majority  of  cases  moist  r^les  are  most  numer- 

Fio  74  — Expio-   ^^^^  during  inspiration  and  especially  during  the  latter 

sion  of  Fine  part  of  this  act.     Their  relation  to  respiration  may  be 

of  Inspiration,   represented  graphically  as  in  Fig.  74,  using  large  dots 

for  coarse  r§,les  and  small  dots  for  fine  rales.     Musical 

r&les  can  be  symbolized  by  the  letter  S  (squeaks). 

(2)  Crackling  Rales. 

These  differ  from  the  preceding  variety  merely  by  the  absence 
of  any  distinct  bubbling  quality.  They  are  usually  to  be  heard  in 
cases  of  bronchitis  in  which  the  secretions  are  unusually  tenacious 
and  viscid.  They  are  especially  apt  to  come  at  the  end  of  inspira- 
tion, a  large  number  being  evolved  in  a  very  short  space  of  time,  so 
that  one  often  speaks  of  an  "  explosion  of  fine  crackling  r&les  "  at 
the  end  of  inspiration.  Crackling  r^les  are  to  be  heard  in  any  one 
of  the  conditions  in  which  bubbling  rales  occur,  but  are  more  fre- 
quent in  tuberculosis  than  in  simple  bronchitis. 

Crepitant  rales,  which  represent  the  finest  sounds  of  this  type, 
are  very  much  like  the  noise  which  is  heard  when  one  takes  a  lock 
of  hair  between  the  thumb  and  first  finger  and  rubs  the  hairs  upon 
each  other  while  holding  them  close  to  the  ear.  A  very  large  num- 
ber of  minute  crackling  sounds  is  heard  following  each  other  in 
rapid  succession.  To  the  inexperienced  ear  they  may  seem  to  blend 
into  a  continuous  sound,  but  with  practice  the  comj)onent  parts  may 


AUSCULTATION.  105 

be  distinguished.  This  type  of  r§.les  is  especially  apt  to  occur  dur- 
ing inspiration  alone,  but  not  very  infrequently  they  are  heard 
during  expiration  as  well.  From  subcrepitant  rales  they  are  dis- 
tinguished mei-ely  by  their  being  still  finer  than  the  latter. '  Sub- 
crepitant rales  are  often  mixed  with  sounds  of  a  somewhat  coarser 
type,  while  crepitant  rales  are  usually  all  of  a  size.  If  the 
chest  is  covered  with  hair,  sounds  precisely  like  these  two  varieties 
of  rales  may  be  heard  v.dien  the  stethoscope  is  placed  upou  the  hairy 
portions.  To  avoid  mistaking  these  sounds  for  rales  one  must 
thorovighly  wet  or  grease  the  hair. 

Crepitant  Rules  in  Atelectasis. 

Crepitant  and  subcrepitant  r§,les  are  very  often  to  be  heard  along 
the  thin  margins  of  the  lungs  at  the  base  of  the  axillae  and  in  the 
back,  especially  when  a  patient  who  is  breathing  superficially  first 
begins  to  take  deep  breaths.  In  such  cases,  they  usually  disappear 
after  the  few  first  resj^irations,  and  are  then  to  be  explained  by  the 
tearing  apart  of  the  slightly  agglutinated  surfaces  of  the  finer  bron- 
chioles. 

It  is  by  no  means  invariably  the  case,  however,  that  such  sub- 
crepitant rales  are  merely  transitory  in  their  occurrence.  In  a  large 
number  of  cases  they  persist  despite  deep  breathing.  The  fre- 
quency of  subcrepitant  r§,les,  persistent  or  transitory,  heard  over 
the  inferior  margin  of  the  normal  lung  at  the  bottom  of  the  axilla, 
is  shown  by  the  following  figures :  Out  of  356  normal  chests  to 
which  I  have  listened  especially  for  these  rRles,  I  found  228,  or  61 
per  cent,  which  showed  them  on  one  or  both  sides.  They  are  very 
rarely  to  be  heard  in  persons  under  twenty  years  of  age.  After 
forty-five,  on  the  other  hand,  it  is  unusual  to  find  them  absent. 
In  my  experience  they  are  considerably  more  frequent  in  the  situa- 
tion shown  in  Fig.  124  than  in  any  other  part  of  the  lung,  but  they 
may  be  occasionally  heard  in  the  back  or  elsewhere.     In  .view  of 

I  A  distinction  was  formerly  drawn  between  crepitant  and  subcrepitant 
rales,  on  the  ground  that  the  latter  were  heard  during  both  respiratory  sounds 
and  the  former  only  during  inspiration,  but  this  distinction  cannot  be  main- 
tained and  is  gradually  being  given  up. 


106    PHYSICAL  DIAGyOSIS  OF  DISEASES  OF  THE  CHEST. 

these  facts,  it  seems  to  me  tliat  we  mvist  recognize  that  it  is  almost 
if  not  quite  physiological  to  find  the  finer  varieties  of  crackling 
rSles  at  the  base  of  the  axillae  in  persons  over  forty  years  old.  I 
have  supposed  these  rales  to  be  due  to  a  partial  atelectasis  result- 
ing from  disease  in  the  thin  lower  margui  of  the  lungs.  Such  por- 
tions of  the  lung  are  ordinarily  not  expanded  unless  the  respirations 
are  forced  and  deep.  This  explanation  would  agree  with  the  obser- 
vations of  Abrams,  to  which  I  shall  refer  later  (see  below,  p.  290). 

(b)  Crepitant  or  subcrepitant  rales  are  also  to  be  heard  in  a 
certain  portion  of  cases  of  pneumonia,  in  the  very  earliest  stages 
and  when  resolution  is  taking  place  ("crepitans  redux").  More 
rarely  this  type  of  rale  may  be  heard  in  connection  with  tubercu- 
losis, infarction,  or  oedema  of  the  lung. 

In  certain  cases  of  dry  pleurisy  there  occur  fine  crackling 
sounds  which  can  scarcely  be  differentiated  from  subcrepitant  rales. 
I  shall  return  to  the  description  of  them  in  speaking  of  pleural 
friction  (see  below,  p.  271). 

(3)  Musical  Rales. 

The  passage  of  air  through  bronchial  tubes  narrowed  by  in- 
flammatory swelling  of  their  lining  membrane  (bronchitis),  gives 
rise  not  infrequently  to  a  multitude  of  musical  sounds.  Such  a 
stenosis  occurring  in  relatively  large  bronchial  tubes  produces  a 
deep-toned  groaning  sound,  while  narrowing  of  the  finer  tubes  re- 
sults in  jjijjing,  squeaking,  tchistUng  noises  of  various  qualities. 
Such  sounds  are  often  known  as  "  dry  rales  "  in  contradistinction 
to  the  "  huhhling  rules  "  above  described,  but  as  many  non-musical 
crackling  rales  have  also  a  very  dry  sound,  it  seems  to  me  best  to 
apply  the  more  distinctive  term  "  tmtsical  rales  "  to  all  adventitious 
sounds  of  distinctly  musical  quality  which  are  i)roduced  in  the 
bronchi.  Musical  rales  are  of  all  adventitious  sounds  the  easiest 
to  i*ecognize  but  also  the  most  fxigitive  and  changeable.  They  ap- 
pear now  here,  now  there,  shifting  from  minute  to  minute,  and  may 
totally  disappear  from  the  chest  and  reappear  again  within  a  very 
short  time.  This  is  to  some  extent  true  of  all  varieties  of  rales, 
but  especially  of  the  squeaking  and  groaning  varieties. 


AUSCULTATION.  107 

Musical  rales  are  heard,  as  a  rule,  more  distinctly  during  expira- 
tion, especially  when  they  occur  in  connection  with  asthma  or  em- 
physema. In  these  diseases  one  may  hear  quite  complicated  chords 
from  the  combinations  of  rales  which  vary  in  pitch. 

VII.   The  Effects  of  Cough. 

The  influence  of  coughing  upon  rales  is  usually  very  marked. 
Its  effect  may  be  either  to  intensify  them  and  bring  them  out  Avhere 
they  have  not  previously  been  heard,  or  to  clear  them  away  alto- 
gether. Other  effects  of  coughing  upon  physical  signs  will  be 
mentioned  later  on  in  the  chapters  on  Pneumonia  and  Phthisis. 

VIII.   Pleural  Fbictiox. 

The  surfaces  of  the  healthy  pleural  cavity  are  lubricated  with 
sufficient  serum  to  make  them  pass  noiselessly  over  each  other  dur- 
ing the  movements  of  respiration.  But  when  the  tissues  become 
abnormally  dry,  as  in  Asiatic  cholera,  or  when  the  serous  surfaces 
are  roughened  by  the  presence  of  a  fibrinous  exudation,  as  in  ordi- 
nary pleurisy,  the  rubbing  of  the  two  pleural  surfaces  against  one 
another  produces  peculiar  and  very  characteristic  sounds  known  as 
^^ pleural  friction  sounds."  The  favorite  seat  of  pleural  friction 
sounds  is  at  the  bottom  of  the  axilla,  i.e.,  where  the  lung  makes 
the  widest  excursion  and  where  the  costal  and  diaphragmatic  pleura 
are  in  close  apposition  (see  Pig.  33).  In  some  cases  pleural  fric- 
tion sounds  are  to  be  heard  altogether  below  the  level  of  the  lung. 
In  others  they  may  extend  up  several  inches  above  its  lower  mar- 
gin, and  occasionally  it  happens  that  friction  may  be  appreciated 
over  the  whole  lung  from  the  top  to  the  bottom.  Very  rarely 
friction  sounds  are  heard  only  at  the  apex  of  the  lung  in  early 
tuberculosis. 

The  sound  of  pleural  friction  may  be  closely  imitated  by  hold- 
ing the  thumb  and  forefinger  close  to  the  ear,  and  rubbing  them 
past  each  other  with  strong  pressure,  or  by  pressing  the  palm  of 
one  hand  over  the  ear  and  rubbing  upon  the  back  of  this  hand  with 


108    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

the  fingers  of  the  other  Pleural  friction  is  usually  a  catchy, 
jerky,  interrupted,  irregular  sound,  and  is  apt  to  occur  during  in- 
spiration only,  and  particularly  at  the  end  of  this  act.  It  may, 
however,  be  heard  with  both  respiratory  acts,  but  rarely  if  ever 
occurs  during  expiration  alone.  The  intensity  and  quality  of  the 
sounds  vary  a  great  deal,  so  that  they  may  be  compared  to  (/razing, 
rubbing,  rasping,  and  creaking  sounds.  They  are  sometimes  spoken 
of  as  "  leathery.''^  As  a  rale,  they  seem  very  near  to  the  ear,  and  are 
sometimes  startlingly  loud.  In  many  cases  tht-y  cannot  be  heard 
after  the  patient  has  taken  a  few  full  breaths,  probably  because  the 
rough  pleural  surfaces  are  smoothed  down  temporarily  by  the  fric- 
tion which  deep  breathing  produces.  After  a  sh(  )rt  rest,  however, 
and  a  period  of  superficial  breathing,  pleural  friction  sounds  often 
return  and  can  be  heard  for  a  short  time  with  all  their  former  in- 
tensity. They  are  increased  by  j^ressure  exerted  upon  the  outside 
of  the  chest  wall.  Such  pressure  had  best  be  made  with  the  hand 
or  with  the  Bowles  stethoscope,  since  the  sharp  edges  of  the  chest- 
piece  of  the  ordinary  stethoscope  may  give  rise  to  considerable 
pain;  but  if  such  pressure  is  made  with  the  hand,  one  must  be 
careful  not  to  let  the  hand  shift  its  position  upon  the  skin,  else 
rubbing  sounds  may  thus  be  produced  which  perfectly  siuiiilate 
pleural  friction.  In  well-marked  cases  pleuritic  friction  can  be 
felt  if  the  palm  of  the  hand  is  laid  over  the  suspected  area;  occa- 
sionally the  sound  is  so  loud  that  it  can  be  heard  by  the  patient 
himself  or  by  those  around  him. 

In  doubtful  cases,  or  when  a  friction  sound  appears  to  have 
disappeared,  and  Avhen  one  Avishes  to  bring  it  out  again,  there  are 
several  manoeuAT."es  suggested  by  Abrams  for  obtaining  this  end. 

(o)  The  Arm  Manoeuvre. 

The  patient  suspends  respiration  altogether,  and  the  arm  upon 
the  affected  side  is  raised  over  the  head  by  the  patient  himself  or 
by  the  physician,  as  in  performing  Sylvester's  method  of  artificial 
respiration.  During  this  movement  we  listen  over  the  suspected  area. 
"  By  this  manoeuvi-e  the  movement  of  the  parietal  against  the  vis- 
ceral pleura  is  opposite  in  direction  to  that  occurring  during  the 


AUSCULTATION.  109 

respiratory  act,  and  for  this  reason  the  pleuritic  sound  may  often 
be  elicited  after  it  has  been  exhausted  in  the  ordinary  act  of  breath- 
ing." 

(h)  The  Decubital  Manoeuvre. 

"Let  the  patient  lie  upon  the  affected  side  for  a  minute  or  two, 
then  let  him  rise  quickly  and  suspend  respiration.  Now  listen  over 
the  aifected  area,  at  the  same  time  directing  the  patient  to  take  a 
deep  breath." 

Pleuritic  friction  sounds  are  distinguished  from  rales  by  their 
greater  superficiality,  by  their  jerky,  interrupted  character,  by  the 
fact  that  they  are  but  little  influenced  by  cough,  and  that  they  are 
increased  by  pressure.  It  has  already  been  mentioned,  however, 
that  there  is  one  variety  of  sounds  which  we  have  every  reason  to 
think  originate  in  the  pleura,  which  cannot  be  distinguished  from 
certain  varieties  of  crackling  bronchial  rales.  Such  sounds  occur 
chiefly  in  connection  with  phthisical  processes,  in  which  both  pleu- 
risy and  bronchitis  are  almost  invariably  present,  and  it  is  seldom 
of  importance  to  distinguish  the  two. 

IX.  Auscultation  of  the  Spoken  or  Whispered  Voice  Sounds. 
The  more  important  of  these  is : 

(a)  The  Whisjyered  Voice. 

The  patient  is  directed  to  whisper  "one,  two,  three,"  or 
"ninety -nine,"  while  the  auscultator  listens  over  different  portions 
of  the  chest  to  see  to  what  degree  the  whispered  syllables  are  trans- 
mitted. In  the  great  majority  of  normal  chests  the  whispered 
voice  is  to  be  heard  only  over  the  trachea  and  primary  bronchi  in 
front  and  behhid,  while  over  the  remaining  portions  of  the  lung 
little  or  no  sound  is  to  be  heard.  When,  on  the  other  hand,  solidi- 
fication of  the  lung  is  present,  the  whispered  voice  may  be  dis- 
tinctly heard  over  }>ortions  of  the  lung  relatively  distant  from  the 
trachea  and  bronchi ;  for  example,  over  the  lower  lobes  of  the  lung 
behind.  The  usefulness  of  the  whispered  voice  in  the  search  for 
small  areas  of  solidification  or  for  the  exact  boundaries  of  a  solidi- 


110     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

fied  area  is  very  great,  especially  when  we  desire  to  save  the  patient 
the  pain  and  fatigue  of  taking  deep  breaths.  Whispered  voice 
sounds  are  practically  equivalent  to  a  forced  expiration  and  can  be 
obtained  with  very  little  exertion  on  the  patient's  part.  The  in- 
creased transmission  of  the  whispered  voice  is,  in  my  opinion,  a 
more  delicate  test  for  solidification  than  tubular  breathing.  The 
latter  sign  is  present  only  Avhen  a  considerable  area  of  lung  tissue 
is  solidified,  Avhile  the  increase  of  the  whispered  voice  may  be  ob- 
tained over  much  smaller  areas.  Retraction  of  the  lung  above  the 
level  of  a  pleural  effusion  causes  a  moderate  increase  in  the  trans- 
mission of  the  whispered  voice,  and  at  times  this  increased  or  bron- 
chial whisper  is  to  be  heard  over  the  fluid  itself,  probably  by  trans- 
mission from  the  compressed  lung  above. 

WTiere  the  lung  is  completely  solidified  the  whispered  words 
may  be  clearly  distinguished  over  the  affected  area.  In  lesser  de- 
grees of  solidification  the  syllables  are  more  or  less  blurred. 

(b)  The  Spolcen  Voice. 

The  evidence  given  us  by  listening  for  the  spoken  voice  in  vari- 
ous parts  of  the  chest  is  considerably  less  in  value  than  that  obtained 
through  the  whispered  voice.  As  a  rule,  it  corresponds  with  the 
tactile  fremitus,  being  increased  in  intensity  by  the  same  causes 
which  increase  tactile  fremitus,  viz.,  solidification  or  condensation 
of  the  lung,  and  decreased  by  the  same  causes  which  decrease  tac- 
tile fremitus — namely,  by  the  presence  of  air  or  Avater  in  the  pleu- 
ral cavity,  by  the  thickening  of  the  pleura  itself,  or  by  an  ob- 
stiTiction  of  the  bronchus  leading  to  the  part  over  which  we  are 
listening.  In  some  cases  the  presence  of  solidification  of  the  lung 
gives  rise  not  merely  to  an  increase  in  transmission  of  the  spoken 
voice,  but  to  a  change  in  its  quality,  so  that  it  sounds  abnormally 
concentrated,  nasal,  and  near  to  the  listener's  ear.  The  latter 
change  may  be  heard  over  areas  where  tactile  fremitus  is  not  in- 
creased, and  even  where  it  is  diminished.  "Where  this  change  in 
the  quality  of  the  voice  occurs,  the  actual  words  spoken  can  often 
be  distinguished  in  a  way  not  usually  possible  over  either  normal 
or  solidified  lung.     ''Bronchophony,"  or  the  distinct  transmission 


AUSCULTATION.  HI 

of  audible  words,  and  not  merely  of  diffuse,  unrecognizable  voice 
sounds,  is  considerably  commoner  in  the  solidification s  due  to  pneu- 
monia than  in  those  due  to  ])hthisis;  it  occurs  in  some  cases  of 
pneumothorax  and  pulmonary  cavity. 

(c)  Egophony. 

Among  the  least  important  of  the  classical  physical  signs  is  a 
nasal  or  squeaky  quality  of  the  sounds  which  reach  the  observer's 
ear  when  the  patient  speaks  in  a  natural  voice.  To  this  j^eeuliar 
quality  of  voice  the  name  of  " egophonj- "  has  been  given.  It  is 
most  frequently-  heard  in  cases  of  moderate-sized  pleuritic  effusion 
just  about  the  level  of  the  lower  angle  of  the  scapula  and  in  the 
vicinity  of  that  point.  Less  often  it  is  heard  at  the  same  level  in 
front.  It  is  verj'  rarely  heard  in  the  upper  portion  of  the  chest 
and  is  by  no  means  constant  either  in  pleuritic  effusion  or  in  any 
other  condition.  A  point  at  which  it  is  heaid  corresponds  not,  as 
a  i-ule,  with  the  upper  level  of  the  accumulated  fluid,  as  has  been 
frequent!)-  supposed,  but  often  with  a  point  about  an  inch  farther 
doA\^l.  The  presence  of  egophony  is  in  no  way  distinctive  of  pleu- 
ritic effusions  and  may  be  heard  occasionally  over  solidified  lung. 

X.  Phenomena  Peculiar  to  Pxeumohtdrothorax  and  Pneu- 

MOPYOTHORAX. 

(1)   Succussion. 

Now  and  then  a  patient  consults  a  physician,  complaining  that 
he  heai'S  noises  inside  him  as  if  water  were  being  shaken  about. 
One  such  patient  expressed  himself  to  me  to  the  effect  that  he  felt 
"like  a  half -empty  bottle."  In  the  chest  of  such  a  patient,  if  one 
presses  the  ear  against  any  portion  of  the  thorax  and  then  shakes 
the  whole  patient  strongly,  one  may  hear  loud  splashing  sounds 
known  technically  as  ''succussion."  Such  sounds  are  absolutely 
diagnostic  of  the  presence  of  both  air  ami  fluid  in  the  caA-ity  over 
which  they  are  heard.  Very  frequently  they  may  be  detected  by 
the  physician  when  the  patient  is  not  aware  of  their  presence.     Oc- 


112     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

casionally  the  splashing  of  the  fluid  within  may  be  felt  as  well  as 
heard.  It  is  essential,  of  course,  to  distinguish  succussion  due  to 
the  presence  of  air  and  fluid  in  the  pleural  cavity  from  similar 
sounds  produced  in  the  stomach,  but  this  is  not  at  all  difficult  in 
the  majority  of  cases.  It  is  a  bare  possibility  that  succussion 
sounds  may  be  due  to  the  presence  of  air  and  fluid  in  the  pericar- 
dial cavity. 

It  is  important  to  remember  that  succussion  is  never  to  be 
heard  in  sunple  pleuritic  effusion  or  hydrothorax.  The  presence  of 
air,  as  Avell  as  liquid,  in  the  pleural  cavity  is  absolutely  essential  to 
the  production  of  succussion  sounds.* 

(2)  Metallic  Tlnlde  or  Fallhuj-Drop  Sound. 

When  listening  over  a  pleural  cavity  which  contains  both  air 
and  fluid,  one  occasionally  hears  a  liquid,  tinkling  sound,  due  pos- 
sibly to  the  impact  of  a  drop  of  liquid  falling  from  the  relaxed 
lung  above  into  the  accumulated  fluid  at  the  bottom  of  the  pleural 
cavity,  and  possibly  to  r§,les  produced  in  the  tissues  around  the 
cavity.  It  is  stated  that  this  physical  sign  may  in  rare  cases  be 
observed  in  large-sized  phthisical  cavities  as  well  as  in  pneumohy- 
drothorax  and  pneumopyothorax. 

(3)  The  Lung-Fistula  Sound. 

When  a  perforation  of  the  lung  occurs  below  the  level  of  the 
fluid  accumulated  in  the  pleural  cavity,  bubbles  of  air  may  be  forced 
out  from  the  lung  and  up  through  the  fluid  with  a  sound  reminding 
one  of  that  made  by  children  when  blowing  soap-bubbles. 

'  It  is  well  for  the  student  to  try  for  himself  the  following  experiment, 
which  I  have  found  useful  in  impressing  these  facts  upon  the  attention  of 
classes  in  physical  diagnosis:  Fill  an  ordinary  rubber  hot-water  bag  to  the 
brim  with  water.  Invert  it  and  squeeze  out  forcibly  a  certain  amount  (per- 
haps half)  of  the  contents,  by  grasping  the  upper  end  of  the  bag  and  compress- 
ing it.  While  the  water  is  thus  being  forced  out,  screw  in  the  nozzle  of  the 
bag.  Now  shake  the  whole  bag,  and  it  will  be  found  impossible  to  produce 
any  splashing  sounds  owing  to  the  fact  that  there  is  no  air  in  the  bag.  Un- 
screw the  nozzle,  admit  air,  and  then  screw  it  in  again,  Now  shake  the  bag 
again  and  loud  splashing  will  be  easily  heard. 


CHAPTER  V. 

AUSCULTATION  OF  THE  HEART. 

I.   '"Valve  Areas." 

In  the  routine  examination  of  the  heart,  most  observers  listen 
in  four  places : 

(1)  At  the  apex  of  the  heart  in  the  fifth  intercostal  space  neai 
the  nipple,  the  ^^ mitral  area." 


Aortic  area,  ""r 


Tricuspid  area. 


—    Pulmonic  area. 


Mitral  area. 


Fig.  75.— The  Valve  Areas. 

(2)  In  the  second  left  intercostal  space  near  the  sternum,  the 
^^ pulmonic  area." 

(3)  In  the  second  right  intercostal  space  near  the  sternum,  the 
"aortic  area." 

(4)  At  the  bottom  of  the  sternum  near  the  ensiform  cartilage, 
the  "  tricuspid  area. " 

These  points   are   represented  in  Fig.   75  and  are  known  as 
8 


114    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

^^ valve  areas."  They  do  not  correspond  to  the  anatomical  position 
of  any  one  of  the  four  valves,  but  exj^erience  has  shown  that  sounds 
heard  best  at  the  apex  can  be  proved  (by  post-mortem  examination 
or  otherwise)  to  be  produced  at  the  mitral  orifice.  Similarly  sounds 
heard  best  in  the  second  left  intercostal  space  are  proved  to  be 
produced  at  the  pulmonary  orifice ;  those  which  are  loudest  at  the 
second  right  intercostal  space  to  be  produced  at  the  aortic  orifice ; ' 
Mobile  those  which' are  most  distinct  near  the  origin  of  the  ensiform 
cartilage  are  produced  at  the  tricuspid  orifice. 

II.  The  Xormal  Heart  Souxds. 

A  glance  at  Fig.  75,  which  represents  the  anatomical  positions 
of  the  four  valves  above  referred  to,  illustrates  what  I  said  above ; 
namely,  that  the  traditional  valve  areas  do  not  correspond  at  all 
with  the  anatomical  position  of  the  valves.  If  now  we  listen  in 
the  ^^ mitral  area,"  that  is,  in  the  region  of  the  apex  imjjulse  of  the 
heart,  keeping  at  the  same  time  one  finger  on  some  point  at  which 
the  cardiac  impulse  is  palpable,  one  hears  Avith  each  outward  thrust 
of  the  heart  a  Ioav,  dull  sound,  and  in  the  period  between  the  heart 
beats  a  second  sound,  shorter  and  sharper  in  quality." 

That  which  occurs  with  the  cardiac  impulse  is  known  as  the 
first  soiind  ;  that  which  occurs  between  each  two  beats  of  the  heart 
is  known  as  the  second  sound.  The  second  sound  is  generally  ad- 
mitted to  be  due  to  the  closure  of  the  semilunar  valves  The  cause 
of  the  first  sound  has  been  a  most  fruitful  source  of  discussion,  and 
no  one  explanation  of  it  can  be  said  to  be  generally  received.  Per- 
haps the  most  commonly  accepted  Anew  attributes  the  first  or 
systolic  sound  of  the  heart  to  a  combination  of  tAvo  elements — 

(a)  The  contraction  of  the  heart  muscle  itself. 

(h)  The  sudden  tautening  of  the  mitral  curtains. 

Following  the  second  sound  there  is  a  pause  corresponding  to 

'    '  For  exceptions  to  this  rule,  see  below,  page  176. 
*  The  first  sound  of  the  heart,  as  heard  at  the  apex,  may  be  imitated  by 
holding  a  linen  handkerchief  by  the  corners  and  suddenly  tautening  one  of  the 
borders.     To  imitate  the  second  sound,  use  one-half  the  length  of  the  border 
instead  of  the  whole. 


AUSCULTATION  OF  THE  HEART. 


115 


the  diastole  of  the  heart.  Normally  this  pause  occupies  a  little 
more  time  than  the  first  and  second  sounds  of  the  heart  taken  to- 
gether.    In  disease  it  may  be  much  shortened. 

The  first  sound  of  the  heart  is  not  only  longer  and  duller  than 
the  second  (it  is  often  sjDoken  of  as  "  booming  "  in  contrast  with  the 
"  snapping  "  quality  of  the  second  sound)  but  is  also  considerably 
more  intense,  so  that  it  gives  us  the  impression  of  being  accented 
like  the  first  syllable  of  a  trochaic  rhythm.  After  a  little  practice 
one  grows  so  accustomed  to  this  rhythm  that  one  is  apt  to  rely  upon 


^^   Aortic  valve. 
Pulmonic  valve. 


Tricuspid  valve. 


Mitral  valve. 


/ 

Fig.  76.— Anatomical  Position  of  the  Cardiac  Valves. 


his  appreciation  of  the  rhythm  alone  for  the  identification  of  the 
systolic  sound.  This  is,  however,  an  unsafe  practice  and  leads  to 
many  errors.  Our  impression  as  to  which  of  the  two  sounds  of  each 
cardiac  cycle  corresponds  to  systole  should  always  be  verified  either 
by  sight  or  touch.  We  must  either  see  or  feel  the  cardiac  impulse 
and  assure  ourselves  that  it  is  synchronous  with  the  heart  sound 
which  we  take  to  be  systolic'  This  point  is  of  especial  importance 
in  the  recognition  and  identification  of  cardiac  murmurs,  as  Avill  be 
seen  presently. 

'  When  the  cardiac  impulse  can  be  neither  seen  nor  felt,  the  pulsation  of 
the  carotid  will  generally  guide  us.     The  radial  pulse  is  not  a  safe  guide. 


116    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

So  far,  I  have  been  describing  the  normal  heart  sounds  heard 
in  the  "mitral  area,"  that  is,  at  the  apex  of  the  heart.  If  now  we 
listen  over  the  pulmonaiy  area  (m  the  second  left  intercostal 
space),  we  find  that  the  rhythm  of  the  heart  sounds  has  changed 
and  that  here  the  stress  seems  to  fall  ui:)on  the  "second  sound," 
i,e.,  that  corresponding  to  the  beginning  of  diastole;  in  other 
words,  the  first  sound  of  the  heart  is  here  heard  more  feebly  and 
the  second  sound  more  distinctly.  The  sharp,  snapping  quality  of 
the  latter  is  here  even  more  marked  than  at  the  apex,  and  despite 
the  feebleness  of  the  first  sound  in  this  area  we  can  usually  recog- 
nize its  relatively  dull  and  prolonged  quality 

Over  the  aortic  area  (i.e.,  in  the  second  right  interspace)  the 
rhythm  is  the  same  as  in  the  pulmonary  area,  although  the  second 
sound  may  be  either  stronger  or  weaker  than  the  corresponding 
sound  on  the  other  side  of  the  sternum  (see  below,  p.  118). 

Over  the  tricuspid  area  one  hears  sounds  practically  indistin- 
guishable in  quality  and  in  rhythm  from  those  heard  at  the  apex. 

When  the  chest  walls  are  thick  and  the  cardiac  sounds  feeble, 
it  may  be  difficult  to  hear  them  at  all.  In  such  cases  the  heart 
sounds  may  be  heard  much  more  distinctly  if  the  patient  leans  for- 
ward and  toward  his  own  left  so  as  to  bring  the  heart  closer  to  the 
front  of  the  chest.  Such  a,  position  of  the  body  also  renders  it 
easier  to  map  out  the  outlines  of  the  cardiac  dubiess  by  percussion. 

In  cardiac  neuroses  and  during  conditions  of  excitement  or  emo- 
tional strain,  the  first  soimd  at  the  apex  is  not  only  very  loud  but 
has  often  a  curious  metallic  reverberation  ("cliquetis  vietallique") 
corresponding  to  the  trembling,  jarring  cardiac  impulse  (often  mis- 
taken for  a  thrill)  which  palpation  reveals. 

III.     MODIFICATIOXS    IN    THE    IXTENSITY    OF    THE    HeART     SoUNDS. 

It  has  already  been  mentioned  that  in  young  persons  with  thin, 
elastic  chests,  the  heart  sounds  are  heard  with  greater  intensity 
than  in  older  persons  whose  chest  walls  are  thicker  and  stiffer. 
In  obese,  indolent  adults  it  is  sometimes  difficult  to  hear  any  heart 
sounds  at  all,  while  in  young  persons  of  excitable  temperament  the 
sounds  may  have  a  very  intense  and  ringing  quality.      Under  dis- 


AUSCULTATION  OF  THE  HEART.  117 

eased  conditions  either  of  the  heart  sounds  may  be  increased  or 
diminished  in  intensity.      I  shall  consider  ' 

(1)  The  First  Soimd  at  the  Apex  [sovietimes  Called  the  Mitral  First 

Soundy 

(a)  Increase  in  the  length  or  intensity  of  the  first  sound  at  the 
apex  of  the  heart  occurs  in  any  condition  which  causes  the  heart 
to  act  with  unusual  degree  of  force,  such  as  bodily  or  mental  exer- 
tion, or  excitement.  In  the  earlier  stages  of  infectious  fevers  a 
similar  increase  in  the  intensity  of  this  sound  may  sometimes  be 
noted.  Hypertrophy  of  the  left  ventricle  sometimes  has  a  similar 
effect  upon  the  sound,  but  less  often  than  one  would  suppose,  while 
dilatation  of  the  left  ventricle,  contrary  to  what  one  would  suppose, 
is  not  infrequently  associated  with  a  loud,  forcible  first  sound  at 
the  apex.  In  mitral  stenosis  the  first  sound  is  usually  very  intense 
and  is  often  spoken  of  as  a  "thumpmg  first  sound  "  or  as  a  "sharp 
slajj." 

(b)  Shortening  and  weakening  of  the  first  sound  at  the  apex. 
In  the  course  of  continued  fevers  and  esi^ecially  in  typhoid  fever 

the  granular  degeneration  which  takes  place  in  the  heart  muscle  is 
manifested  by  a  shortening  and  weakening  of  the  first  sound  at  the 
apex,  so  that  the  two  heart  sounds  come  to  seem  much  more  alike 
than  usual.  In  the  later  stages  of  typhoid,  the  first  sound  may 
become  almost  inaudible.  The  sharp  "valvular  "  quality,  which 
one  notices  in  the  first  apex  sound  under  these  conditions,  has  been 
attributed  to  the  fact  that  weakening  of  the  myocardium  has  caused 
a  suppression  of  one  of  the  two  elements  which  go  to  make  up  the 
first  sound,  namely,  the  muscular  element,  so  that  we  hear  only  the 
short,  sharp  sound  due  to  the  tautening  of  the  mitral  curtains. 
Chronic  myocarditis,  or  any  other  change  in  the  heart  wall  which 
tends  to  enfeeble  it,  produces  a  weakening  and  shortening  of  the 
first  sound  similar  to  that  just  describedo  Simple  weakness  in  the 
mitral  first  sound  without  any  change  in  its  duration  or  pitch  may 
be  due  to  fatty  overgrowth  of  the  heart,  to  emphysema  or  pericar- 
dial effusion  in  case  the  heart  is  covered  by  the  distended  lung  or 
by  the  accumulated  fluid.     Among  vahnilar  diseases  of  the  heart 


|118    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

the  one  most  likely  to  be  associated  with  a  diminution  in  intensity 
of  the  first  apex  sound  is  mitral  regurgitation. 

(c)  Doubling  of  the  first  sound  at  the  apex. 

It  is  not  uncommon  in  healthy  hearts  to  hear  in  the  region  of 
the  apex  impulse  a  cfoubling  of  the  first  sound  so  that  it  may  be 
suggested  by  pronouncing  the  syllables  "turrupp  "  or  "trupp."  In 
health  this  is  especially  apt  to  occur  at  the  end  of  expiration.  In 
disease  it  is  associated  with  many  diiferent  conditions  involving  an 
increase  in  the  work  of  one  or  the  other  side  of  the  heart.  It 
seems,  however,  to  be  unusually  frequent  in  myocarditis. 

(2)  Modifications  in  the  Second  Sounds  as  Heard  at  the  Base  of  the 

Heart. 

Physiological  Variations. — The  relative  intensity  of  the  pul- 
monic second  sound,  when  compared  with  the  second  sound  heard 
in  the  conventional  aortic  area,  varies  a  great  deal  at  different  pe- 
riods of  life.  Attention  was  first  called  to  this  by  Vierordt,'  and 
it  has  of  late  years  been  recognized  by  the  best  authorities  on  dis- 
eases of  the  heart,  though  the  majority  of  current  text-liooks  still 
repeat  the  mistaken  statement  that  the  aortic  second  sound  is  always 
louder  than  the  pulmonic  second  in  health. 

The  work  of  Dr.  Sarah  E.  Creighton,  done  in  my  clinic  during 
the  summer  of  1899,  showed  that  in  90  per  cent  of  healthy  chil- 
dren under  ten  years  of  age,  the  pulmonic  second  sound  is  louder 
than  the  aortic.  In  the  next  decade  (from  the  tenth  to  the  twen- 
tieth year)  the  pulmonic  second  sound  is  louder  in  two-thirds  of 
the  cases.  About  half  of  207  cases,  between  the  ages  of  twenty  and 
twenty-nine,  showed  an  accentuation  of  the  pulmonic  second,  Avhile 
after  the  thirtieth  year  the  number  of  cases  showing  such  accentua- 
tion became  smaller  with  each  decade,  until  after  the  sixtieth  year 
we  found  an  accentuation  of  the  ao7'tic  second  insixtij-six  out  of  sixty- 
eight  cases  examined.     These  facts  are  exhibited  in  tabular  form  in 

'Vierordt:  "Die  Messung  der  Intensitat  der  Herztone"  (Tubingen, 
1885).  See  also  Hochsinger,  "Die  Auscultation  des  kindlichen  Herzeiis"; 
Gibson,  "Diseases  of  the  Heart"  (1898)  ;  Rosenbach,  "Diseases  of  the  Heart" 
(1900) ;  AUbutt,  "System  of  Medicine." 


AUSCULTATION  OF  THE  HEART. 


119, 


Figs.  77  and  78,  and  appear  to  show  that  the  relative  intensity  of 
the  two  sounds  in  the  aortic  and  pulmonic  arteries  depends  pri- 
marily upon  the  age  of  the  individual,  the  pulmonic  sound  predomi- 
nating in  youth  and  the  aortic  in  old  age,  while  in  the  period  of 
middle  life  there  is  relatively  little  discrepancy  between  the  two. 


DECADES. 


100%- 



100% 

90%- 

\ 

—90% 

\ 

80%- 

\ 

80% 

V 

70%- 

\ 

—70% 

V 

\ 

— co% 

50% 

m 

33 

o 

m 

\ 

TAG 

\ 

CO 

L 

--40% 

\ 

30%- 

\ 

30% 

\ 

20%- 

\ 

20% 

\ 

10%- 

v- 

'\ 

in'k' 

V 

Fig. 


-Showing  the  Per  Cent  of  Accentuated  Pulmonic  Second  Sound  In  Each  Decade 
Based  on  1,000  cases. 


It  is,  therefore,  far  from  true  to  suppose  that  we  can  obtain  evi- 
dence of  a  pathological  increase  in  the  intensity  of  either  of  the 
second  sounds  at  the  base  of  the  heart  simply  by  comparing  it  with 
the  other.  Pathological  accentuation  of  the  pulmonic  second 
sound  must  mean  a  greater  loudness  of  this  sound  than  should 
be  expected  at  the  age  of  the  patient  in  qnestion,  and  not  simply  a 
greater  intensity  than  that  of  the  aortic  second  sound.     The  same 


120    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

observation  obviously  applies  to  accentuation  of  the  aortic  second 
soimd. 

Both  the  aortic  and  the  pulmonic  second  sounds  are  sometimes 


mX- 


DECADES. 

:        !       ;        ;        i        ;        I        i        ! 

I   0-9   i  10-19 1  20-29  ]  30-39  1 40-49  |  50-59   60-69  |  70-79 ' 


Fig.  78.— Showing  the  Per  Cent  of  Accentuated  Pulmonic  Second  Sound  in  Each  Decade. 

Based  on  1,000  cases. 

very  intense  during  great  emotional  excitement  or  after  muscular 
exertion,  and  sometimes  without  any  obvious  cause. 

Pathological   Variations. 

A.  Accentuation  of  the  Pidmonic  Second  J^ound. 

Pathological  accentuation  of  the  second  sound  occurs  especially 
in  conditions  involving  a  backing  up  of  blood  in  the  lungs,  such  as 
occurs  in  stenosis  or  insufficiency  of  the  mitral  valve,  or  in  obstruc 


AUSCULTATION  OF  THE  HEART.  121 

tive  disease  of  the  lungs  (emphysema,  bronchitis,  phthisis,  chronic 
interstitial  pneumonia).  Indirectly  accentuation  of  the  pulmonic 
second  sound  pomts  to  hypertrophy  of  the  right  ventricle,  since 
without  such  hypertrophy  the  work  of  driving  the  blood  through 
the  obstructed  lung  could  not  long  be  performed.  If  the  right  ven- 
tricle becomes  weakened,  the  accentuation  of  the  pulmonic  second 
sound  is  no  longer  heard. 

B.    Weakening  of  the  Ptihnonic  Second  Sound. 

Weakening  of  the  pubnonic  second  sound  is  a  very  serious  symp- 
tom, sometimes  to  be  observed  in  cases  of  pneumonia  or  cardiac 
disease  near  the  fatal  termination.  It  is  thus  a  very  important 
indication  for  prognosis,  and  is  to  be  watched  for  with  the  greatest 
attention  in  such  cases. 

C  Aceetituation  of  the  Aortic  Second  Sound. 

I  have  already  shown  that  the  aortic  second  sound  is  louder 
than  the  correspondmg  sound  in  the  pulmonary  area  in  almost  every 
individual  over  sixty  years  of  age  and  in  most  of  those  over  forty. 
A  still  greater  mtensity  of  the  aortic  second  sound  occurs — 

(rt)  In  interstitial  nephritis  or  any  other  condition  which  in- 
creases arterial  tension  and  so  throws  an  increased  amount  of  work 
upon  the  left  ventricle.  Indirectly,  therefore,  a  pathologically  loud 
aortic  sound  points  directly  to  increased  tension  in  the  peripheral 
arteries  and  indirectly  to  hyjjertrophy  of  the  left  ventricle. 

(J})  A  similar  increase  in  the  intensity  of  the  aortic  second 
sound  occurs  in  aneurism  or  diffuse  dilatation  of  the  aortic  arch, 

D.  Dlmimition  in  the  Intensity  of  the  Aortic  Second  Sound. 

Whenever  the  amount  of  blood  thrown  into  the  aorta  by  the 
contraction  of  the  left  ventricle  is  diminished,  as  is  the  case  espe- 
cially in  mitral  stenosis  and  to  a  lesser  degree  in  mitral  regurgita- 
tion, the  aortic  second  sound  is  weakened  so  that  at  the  apex  it 
may  be  inaudible.  A  similar  effect  is  produced  by  any  disease 
which  weakens  the  walls  of  the  left  ventricle,  such  as  fibrous  myo- 


122     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

carditis,  fatty  degeneration,  and  cloudy  swelling.  Relaxation  of 
the  peripheral  arteries  has  the  same  effect.  In  conditions  of  col- 
lapse the  aortic  second  sound  may  be  almost  or  quite  inaudible. 

In  persons  past  middle  life  the  second  sounds  are  often  louder 
in  the  third  or  fourth  hiterspace  than  in  the  second,  so  that  if  we 
listen  only  in  the  second  space  we  may  gain  the  false  impression  that 
the  second  sounds  are  feeble. 

Accentuation  of  both  the  second  sounds  at  the  base  of  the 
heart  may  occur  in  health  from  nervous  causes  or  Avheu  the  lungs 
are  retracted  by  disease  so  as  to  uncover  the  conus  arteriosus  and 
the  aortic  arch.  Under  these  conditions  the  second  sound  may  be 
seen  and  felt  as  well  as  heard.  In  a  similar  way,  an  apparent  in- 
crease in  the  intensity  of  either  one  of  the  second  sounds  at  the 
base  of  the  heart  may  be  produced  by  a  retraction  of  one  or  the 
other  lung. 

Siunmarij. — (1)  The  mitral  first  sound  is  mcreased  by  hyper- 
trophy or  dilatation  of  the  left  ventricle,  and  among  vaUiilar  dis- 
eases especially  by  mitral  stenosis.  It  is  weakened  or  reduplicated 
by  parietal  disease  of  the  heart.  Any  of  these  changes  may  occur 
temporarily  from  physiological  causes. 

(2)  The  7:)?</»io?ii*c  second  sound  is  usually  more  intense  than 
the  aortic  in  children  and  up  to  early  adult  life.  Later  the  aortic 
second  soimd  predominates.  Pathological  accentuation  of  the  sec- 
ond pulmonic  sound  usually  points  to  obstruction  in  the  pulmonary 
circulation  (mitral  disease,  emphysema,  etc.).  "Weakening  of  the 
pulmonic  second  means  failure  of  the  right  ventricle  and  is  serious. 

(3)  The  doHic  second  sound  is  increased  pathologically  by  any 
cause  which  increases  the  work  of  the  left  ventricle  (arteriosclero- 
sis, chronic  nephritis).  It  is  diminished  when  the  blood  stream, 
thrown  into  the  aorta  by  the  left  ventricle,  is  abnormally  small 
(mitral  disease,  cardiac  failure). 

(4)  Changes  in  the  tricuspid  sounds  are  rarely  recognizable, 
while  changes  in  the  first  aortic  and  pulmonic  sounds  have  little 
practical  significance. 


AUSCULTATION  OF  THE  HEART.  123 

Modifications  in  the  Rhythm  of  the  Cardiac  Sounds. 

(1)  Whenever  the  walls  of  the  heart  are  greatly  weakened  by 
disease,  for  example,  in  the  later  weeks  of  a  case  of  typhoid 
fever,  the  diastolic  pause  of  the  heart  is  shortened  so  that  the  car- 
diac sounds  follow  each  other  almost  as  regularly  as  the  ticking  of 
a  clock;  hence  the  term  ^''tick-tack  heart."  As  this  rhythm  is  not 
unlike  that  heard  in  the  foetal  heart,  the  name  of  '^  emhryocardia  "' 
is  sometimes  applied  to  it.  The  "  tick-tack  "  rhythm  may  be  heard 
in  any  form  of  cardiac  disease  after  compensation  has  failed,  or  in 
any  condition  leading  to  collapse. 

(2)  A  less  common  change  of  rhythm  is  that  produced  by  a 
shortening  of  the  interval  between  the  two  heart  sounds  owing  to 
an  incompleteness  of  the  contraction  of  the  ventricle.  This  change 
may  occur  in  any  disease  of  the  heart  when  compensation  fails. 

(3)  Tlie  "  Gallop  Rhythm.''^ — Shortening  of  the  diastolic  pause 
together  with  doubling  of  one  or  another  of  the  cardiac  sounds  re- 
sults in  our  hearing  at  the  apex  of  the  heart  three  sounds  instead 
of  two,  which  follow  each  other  in  a  rhythm  suggesting  the  hoof 
beats  of  a  galloping  horse.  Such  a  rhythm  may  occur  temporarily  in 
any  heart  which  is  excited  or  overworked  from  any  cause,  but  when 
permanent  is  usually  a  sign  of  grave  cardiac  weakness.  The  rhythms 
so  produced  are  usually  anapaestic,  ^-^  ^^ — ',  ^^  ^-^ — ',  -^^^ — ',  or  of 
this  type :  ^-^  — '  ^w,  ^^  — '  ^^,  -^  — '  -^y. 

Doubling  of  the  Second  Sounds  at  the  Base  of  the  Heart. — At 
the  end  of  a  long  inspiration  this  change  may  be  observed  in  al- 
most any  healthy  person  if  one  listens  at  the  base  of  the  heart.  It 
is  still  better  brought  out  after  muscular  exertion  or  by  holding  the 
breath.  In  such  cases  it  probably  expresses  the  non-synchronous 
closure  of  the  aortic  and  pulmonic  valves,  owmg  to  increased  press- 
ure in  the  pulmonary  circulation.  Similarly  in  diseased  condi- 
tions, anything  which  increases  the  pressure  either  in  the  periph- 
eral arteries  or  in  the  pulmonaiy  circulation,  and  thus  throws 
increased  work  upon  one  or  the  other  ventricle,  will  cause  a  doub- 
ling of  the  second  sound  as  heard  at  the  base  of  the  heart. 

In  mitral  stenosis  a  double  diastolic   sound  is  usually  to  be 


124    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

heard  at  the  apex,  and  in  the  diagnosis  of  this  disease  this  "  double 
shock  sound "  during  diastole  may  be  an  important  piece  of  evi- 
dence, and  may  sometimes  be  felt  as  well  as  heard.  The  "  double 
shock  sound  "  of  mitral  stenosis  is  not  generally  believed  to  repre- 
sent a  doubling  of  the  ordinary  second  sound,  although  it  corre- 
sponds with  diastole.     Just  what  its  mechanism  is,  is  disputed. 

I  have  said  nothing  about  modifications  in  the  second  sound  at 
the  apex,  since  this  sound  is  now  generally  agreed  to  represent  the 
aortic  second  sound  transmitted  by  the  left  ventricle  to  the  apex. 
The  first  sounds  at  the  base  of  the  heart  have  also  not  been  dwelt 
upon,  since  they  have  no  special  importance  in  diagnosis. 

Metallic  Heart  Sounds. 

The  presence  of  air  in  the  immediate  vicinity  of  the  heart, 
as,  for  example,  in  pneumothorax  or  in  gaseous  distention  of  the 
stomach  or  intestine,  may  impart  to  the  heart  sounds  a  curious 
metallic  quality  such  as  is  not  heard  under  any  other  conditions. 

*^  Muffling,"  "'Prolongation"  or  "  Vncleamess"  of  the  HeaH  Sounds. 

These  terms  are  not  infrequently  met  with  in  literature,  but 
their  use  should,  I  think,  be  discontinued.  The  facts  to  which 
they  refer  should  be  explained  either  as  faintness  of  the  heart 
sounds,  due  to  the  causes  above  assigned,  or  as  faint,  short  mur- 
murs. In  their  present  usage  such  terms  as  "  muffled  "  or  "  unclear  " 
heart  sounds  represent  chiefly  an  unclearness  in  the  mind  of  the 
observer  as  to  just  what  it  is  that  he  hears,  and  not  any  one  recog- 
nized pathological  condition  in  the  heart. 

IV.  SouxDS  Audible  Over  the  Periphekal  Vessels. 

(1)  The  normal  heart  sounds  are  in  adults  audible  over  the 
carotids  and  over  the  subclavian  arteries.  In  childhood  and  youth 
only  the  second  heart  sound  is  thus  audible. 

(2)  In  about  7  per  cent  of  normal  persons  a  systolic  sound  can 
be  heai'd  over  the  femoral  artery.     This  sound  is  ob\dously  not 


AUSCULTATION  OF  THE  HEART.  125 

transmitted  from  the  heart,  and  is  usually  explained  as  a  result  of 
the  sudden  systolic  tautening  of  the  arterial  wall. 

In  aortic  regurgitation  this  arterial  sound  is  almost  always 
audible  not  only  in  the  femoral  but  in  the  brachial  and  even  in  the 
radial,  and  its  intensity  over  the  femoral  becomes  so  great  that  the 
term  "pistol-shot"  sound  has  been  applied  to  it.  In  fevers, 
exophthalmic  goitre,  lead  poisoning,  and  other  diseases,  a  similar 
arterial  sound  is  to  be  heard  much  more  frequently  than  in  health. 

Venous  Sounds. 

The  violent  closure  of  the  venous  valves  in  the  jugular  is  some- 
times audible  in  cases  of  insufficiency  of  the  tricuspid  valve.  The 
found  has  no  clinical  importance,  and  is  difficult  to  distinguish  owing 
to  the  presence  of  the  carotid  first  sound  mentioned  above. 


CHAPTER  YL 

AUSCULTATION  OF  THE  HEART:  CONTINUED. 

Cardiac  Murmurs. 

(«)  Terminology. 

The  word  "  viurmur  "  is  one  of  the  most  unfortunate  of  all  tlie 
terms  used  in  the  deserij)tion  of  physical  signs.  Xo  one  of  the 
various  blowing,  whistling,  rolling,  rumbling,  or  piping  noises  to 
which  the  term  refers,  sounds  anything  like  a  "  murmur  "  in  the 
ordinaiy  sense  of  the  word.  Nevertheless,  it  does  not  seem  best 
to  try  to  replace  it  by  any  other  term.  The  French  word  "  souffle  " 
is  much  more  accurate  and  has  become  to  some  extent  Anglicized. 
Under  the  head  of  cardiac  murmurs  are  mcluded  all  abnormal 
sounds  produced  within  the  heart  itself.  Pericardial  friction 
sounds  and  those  produced  in  that  portion  of  the  lung  or  pleura 
which  overlies  the  heart  are  not  considered  "murmurs." 

(U)  Mode  of  Production. 

With  rare  exceptions  all  cardiac  murmurs  are  produced  at  or 
near  one  of  the  valve  orifices,  either  by  disease  of  the  valves  them- 
selves resulting  in  shrivelling,  thickening,  stiffenmg,  and  narrowing 
of  the  valve  curtains,  or  by  a  stretching  of  the  orifice  into  which 
the  valves  are  inserted. 

Diseases  of  the  valves  themselves  may  lead  to  the  production  of 
murmurs : 

(a)  AMien  tlie  valves  fail  to  close  at  the  proper  time  (incompe- 
tence, insufficiency,  or  regurgitation). 

(b)  AYhen  the  valves  fail  to  open  at  the  proper  time  (stenosis 
or  obsti-uction) . 


AUSCULTATION  OF  THE  HEART.  127 

(c)  When  the  surfaces  of  the  valves  or  of  the  parts  immedi- 
ately adjacent  are  roughened  so  as  to  i)revent  the  smooth  flow  of  the 
blood  over  them. 

{d)  "When  the  orifice  which  the  valves  are  meant  to  close  is  di- 
lated as  a  result  of  dilatation  of  the  heart  chamber  of  which  it  forms 


Fig.  79.— Diajarram  to  Illustrate  the  Production  of  a  Cardiac  Murmur  Through  Regurgitation 
from  the  Aorta  or  in  an  Aneurismal  Sac.  The  arrow  shows  the  direction  of  the  blood  cur- 
rent and  the  curled  lines  the  audible  blood  eddies. 

the  entrance  or  exit.  The  valves  themselves  cannot  enlarge  to 
keep  pace  with  the  enlargement  of  the  orifice,  and  hence  no  longer 
suffice  to  reach  across  it. 

The  presence  of  any  one  of  these  lesions  gives  rise  to  eddies 
in  the  blood  current  and  thereby  to  the  abnormal  sounds  to  which 
we  give  the  name  murmurs.'     (See  Figs.  79,  80,  and  81).     When 


Q   . 


Fig.  80.— Diagram  to  Illustrate  the  Production  of  a  Cardiac  Murmur  Through  Stenosis  of  a 

Valve-Oriflce. 

valves  fail  to  close  and  so  allow  the  blood  to  pass  back  through 
them,  we  speak  of  the  lesion  as  regurgitation,  insiffficiency,  or  in- 
competeyice ;  if,  for  example,  the  aortic  valves  fail  to  close  after 
the  left  ventricle  has  thrown  a  column  of  blood  into  the  aorta, 
some  of  this  blood  regurgitates  through  these  valves  into  the  ven- 

'  The  method  by  which  functional  murmurs  are  produced  will  be  discussed 
later.     (See  page  136.) 


128    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

tricle  from  which  it  has  just  been  expelled,  and  we  speak  of  the 
lesion  as  "aortk  regurgitation,"  and  of  the  murmur  so  produced  as 
an  aortic  regurgitant  murmur  or  a  murmur  of  aortic  regurgitation. 
A  similar  regurgitation  from  the  left  ventricle  into  the  left  auricle 
takes  place  in  case  the  mitral  valve  fails  to  close  at  the  beginning 
of  systole.  If,  on  the  other  hand,  the  mitral  valve  fails  to  open 
properly  to  admit  the  blood  which  should  flow  during  diastole  from 
the  left  auricle  into  the  left  ventricle,  we  speak  of  the  condition  as 
mitral  stenosis  or  mitral  obstruction.  A  shnilar  narrowing  of  the 
aortic  valves  such  as  to  hinder  the  egress  of  blood  during  the  systole 
of  the  left  ventricle  is  known  as  aortic  stenosis  or  obstruction.    Val- 


Fio.  81.— Diagram  to  Illustrate  the  Production  of  Cardiac  Murmurs  Through  Roughening  of  a 

Valve. 

vular  lesions  of  the  right  side  of  the  heart  (tricuspid  and  pulmonic 
valves)  are  comparatively  rare,  but  are  produced  and  named  in  a 
way  similar  to  those  just  described. 

The  facts  most  important  to  know  about  a  murmur  are : 

(1)  Its  place  in  the  cardiac  cycle. 

(2)  Its  point  of  maxunum  intensity. 

(3)  The  area  over  which  it  can  be  heard. 

(4)  The  effects  of  exertion,  respiration,  or  position  upon  it. 
Less  important  than  the  above  ai-e : 

(5)  Its  intensity. 

(6)  Its  quality. 

(7)  Its  length. 

(8)  Its  relation  to  the  normal  sounds  of  the  heart. 
Each  of  these  points  will  now  be  taken  up  in  detail : 

(1)  Time  of  Murmurs. — The  first  and  most  important  thing  to 
ascertain  regarding  a  murmur  is  its  relation  to  the  normal  cardiac 
cycle ;  that  is,  whether  it  occurs  during  systole  or  during  diastole, 
or  in  case  it  does  not  fill  the  whole  of  one  of  those  periods,  in  what 


AUSCULTATION  OF  THE  HEART.  129 

part  of  systole  or  diastole  it  occurs.  It  must  be  borne  in  mind  that 
the  period  of  systole  is  considered  as  lasting  from  the  begmning  of 
the  first  sound  of  the  heart  up  to  the  occurrence  of  the  second 
sound,  while  diastole  lasts  from  the  beginnmg  of  the  second  sound 
until  the  beginning  of  the  first  sound  in  the  next  cycle.  Any  mur- 
mur occurring  with  the  first  sound  of  the  heart,  or  at  the  time  when 
the  first  sound  should  take  place,  or  in  any  part  of  the  period  inter- 
vening between  the  first  sound  and  the  second,  is  held  to  be  systolic. 
Murmurs  which  distinctly  follow  the  first  sound  or  do  not  begin 
until  the  first  sound  is  ended  are  known  as  late  systolic  murmurs. 

On  the  other  hand,  it  seems  best,  for  reasons  to  be  discussed 
more  in  detail  later  on,  not  to  give  the  name  of  diastolic  to  all 
murmurs  which  occur  within  the  diastolic  period  as  above  defined, 
IMurmurs  which  occur  during  the  last  part  of  diastole  and  which 
run  up  to  the  first  sound  of  the  next  cycle  are  usually  known  as 
^'' 2)resystolic  "  murmurs.  All  other  murmurs  occurring  during  dias- 
tole are  known  as  diastolic. 

The  commonest  of  all  the  errors  in  the  diagnosis  of  disease  of 
the  heart  is  to  mistake  systole  for  diastole,  and  thereby  to  misin- 
terpret the  significance  of  a  murmur  heard  during  those  periods. 
This  mistake  would  never  happen  if  we  were  always  careful  to 
make  sure,  by  means  of  sight  or  touch,  just  when  the  systole  of 
the  heart  occurs.  This  may  be  done  by  keeping  one  finger  upon 
the  apex  impu.lse  of  the  heart  or  upon  the  carotid  artery  while 
listening  for  murmurs,  or,  in  case  the  apex  impulse  or  the  pulsa- 
tions of  the  carotid  are  better  seen  than  felt,  we  can  control  by  the 
eye  the  impressions  gained  by  listening.  It  is  never  safe  to  tnist 
our  appreciation  of  the  cardiac  rhythm  to  tell  us  which  is  the  first 
heart  sound  and  which  the  second.  The  proof  of  this  statement 
is  given  by  the  numberless  mistakes  made  through  disregarding  it. 
Equally  untrustworthy  as  a  guide  to  the  time  of  systole  and  dias- 
tole is  the  radial  pulse,  which  follows  the  cardiac  systole  at  an 
interval  just  long  enough  to  mar  our  calculations. 

(2)  Localizations  of  Murmurs. — To  localize  a  murmur  is  to  find 
its  point  of  maximum  intensity,  and  this  is  of  the  greatest  impor- 
tance in  diagnosis.     Long   experience   has   shown  that  murmurs 
9 


130     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

heard  loudest  iu  the  region  of  the  apex  beat  (whether  this  is  in  the 
normal  situation  or  displaced),  are  m  the  vast  majority  of  cases  jiro- 
duced  at  the  mitral  valve.  In  about  five  per  cent  of  the  cases  mitral 
murmurs  may  be  best  heard  at  a  point  midway  between  the  i)osition 
of  the  normal  cardiac  impulse  and  the  ensiform  cartilage,  or  (very 
rarely)  an  inch  or  two  above  this  situation. 

Murmurs  heard  most  loudly  in  the  second  left  intercostal  space 
are  almost  invariably  produced  at  the  pulmonic  orifice  or  just  above 
it  in  the  conns  arteriosus. 

Murmurs  whose  maximum  intensity  is  at  the  root  of  the  ensi- 
form cartilage  or  within  a  radius  of  an  inch  and  a  half  from  this 
point  are  usually  produced  at  the  tricuspid  orifice.  Murmurs  pro- 
duced at  the  aortic  orifice  may  be  heard  best  in  the  aortic  area,  but 
in  a  large  proportion  of  cases  are  loudest  on  the  other  side  of  the 
sternum  at  or  about  the  situation  of  the  fourth  left  costal  cartilage. 
Occasionally  they  are  best  heard  at  the  apex  of  the  heart  or  over 
the  lower  part  of  the  sternum  (see  above.  Fig.  103). 

(3)  Transmission  of  Ilurmurs. — If  a  murmur  is  audible  over  sev- 
eral valve  areas,  the  questions  naturally  arise :  "  How  are  we  to 
know  whether  we  are  dealing  with  a  smgle  valve  lesion  or  with 
several?  Is  this  one  murmur  or  two  or  three  murmurs?  "  Obvi- 
ously the  question  can  be  asked  only  in  case  the  murmur  which  we 
find  audible  in  various  places  occupies  everywhere  the  same  time 
in  the  cardiac  cycle.  It  must,  for  example,  be  everywhere  systolic 
or  ever3rsvhere  diastolic.  A  systolic  murmur  at  the  apex  cannot 
be  supposed  to  point  to  the  same  lesion  as  a  diastolic  murmur,  no 
matter  where  the  latter  is  heard.  But  if  we  hear  a  systolic  mur- 
mur in  various  parts  of  the  chest,  say  over  the  aortic,  mitral,  and 
tricuspid  regions,  how  are  we  to  know  whether  the  sound  is  simple 
or  compound,  whether  produced  at  one  valve  orifice  or  at  several? 

This  question  is  sometimes  difficult  to  answer,  and  in  a  given 
case  skilled  observers  may  differ  in  their  verdict,  but,  as  a  rule,  the 
difficulty  may  be  overcome  as  follows : 

(1)  Experience  and  post-mortem  examination  have  shown  that 
the  murmur  produced  by  each  of  the  vahiilar  lesions  has  its  own 
characteristic  area  of  propagation,  over  which  it  is  heard  with  an  in- 


AUSCULTATION  OF  THE  HEART.  131 

tensity  which  regularly  diminishes  as  we  recede  from  a  maximum 
whose  seat  corresponds  with  some  one  of  the  valve  areas  just  de- 
scribed. These  areas  of  propagation  are  shown  in  Figs.  91,  92,  95, 
and  100.  Any  murmur  whose  distribution  does  not  extend  beyond 
one  of  these  areas,  and  which  steadily  and  progressively  diminishes 
in  intensity  as  we  move  away  from  the  valve  area  over  which  it  is 
loudest,  may  be  assumed  to  be  due  to  a  single  valve  lesion  and  no 


Fig.  82.— Mitral  and  Tricuspid  Regurgitation.    The  intensity  of  the  systolic  murmur  is  least  at 
the  "  waist "  of  the  shaded  area  and  Increases  as  one  approaches  either  end  of  It. 

more.     Provided  but  one  valve  is  diseased,  this  course  of  procedure 
gives  satisfactory  results. 

(2)  When  several  valves  are  diseased  and  several  murmurs  may 
be  expected,  it  is  best  to  start  at  some  one  valve  area,  say  in  the 
mitral  or  apex  region,  and  move  the  stethoscope  one-half  an  inch 
at  a  time  toward  one  of  the  other  valve  areas,  noting  the  intensity 
of  any  murmur  we  may  hear  at  each  of  the  different  points  passed 
over.  As  we  move  toward  the  tricuspid  area,  we  may  get  an  im- 
j)ression  best  expressed  by  Fig.  82.  That  is,  a  systolic  mvirmur 
heard  loudly  at  the  apex  may  fade  away  as  we  move  toward  the 
ensiform,  until  at  the  point  x  (Fig.  82)  it  is  almost  inaudible.  But 
as  we  go  on  in  the  same  direction  the  murmur  may  begin  to  grow 


132    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

louder  (and  perhaps  to  change  in  pitch  and  quality  as  well)  until  a 
maximum  is  reached  at  the  tricuspid  area,  beyond  which  the  mur- 
mur again  fades  out. 

These  facts  justify  us  in  sus2yecting  that  we  are  dealing  with  two 
murmurs,  one  produced  at  the  tricuspid  and  one  at  the  mitral  ori- 
fice. The  suspicion  is  more  likely  to  be  correct  if  there  has  been 
a  chaiige  in  the  pitch  and  quality  of  the  murmur  as  we  neared  the 
tricuspid  orifice,  and  may  be  confirmed  by  the  discovery  of  other 
evidences  of  a  double  lesion.  Xo  diagnosis  is  satisfactory  ichich 
rests  on  the  evidence  of  murmurs  alone.  Changes  in  the  size  of 
the  heai't's  chambers  or  in  the  pulmonary  or  peripheral  circulations 
are  the  most  important  facts  in  the  case.  Nevertheless  the  effort 
to  ascertain  and  graphically  to  represent  the  intensity  of  cardiac 
murmurs  as  one  listens  along  the  line  connecting  the  valve  areas 
has  its  value.  An  "hour-glass  "  murmur,  such  as  that  represented 
in  Fig.  82,  generally  means  tivo-valve  lesions.  A  similar  "hour- 
glass "  may  be  found  to  represent  the  auditory  facts  as  we  move 
from  the  mitral  to  the  pulmonic  or  to  the  aortic  areas  (see  Fig. 
83),  and,  as  in  the  previous  case,  arouses  our  suspicion  that  more 
than  one  valve  is  diseased. 

It  must  not  be  forgotten,  however,  that  "  a  murmur  may  travel 
some  distance  underground  and  emerge  with  a  change  of  quality  " 
(AUbutt).  This  is  especially  true  of  aortic  murmurs,  which  are  often 
heard  well  at  the  apex  and  at  the  aortic  area,  and  faintly  in  the  iii- 
tervening  space,  probably  owing  to  the  interposition  of  the  right 
ventricle. 

In  such  cases  we  must  fall  back  upon  the  condition  of  the  heart 
itself,  as  shown  by  inspection,  palpation,  and  percussion,  and  upon 
the  condition  of  the  pulmonary  and  peripheral  circulation,  as 
shown  in  the  other  symptoms  and  signs  of  the  cases  (dropsy,  cough, 
etc.). 

(4)  Intensity  of  Murmurs. — Sometimes  murmurs  are  so  loud 
that  they  are  audible  to  the  patient  hunself  or  even  at  some  dis- 
tance from  the  chest.  In  one  case  I  was  able  to  hear  a  murmur 
eight  feet  from  the  patient.  Such  cases  are  rare  and  usually  not 
serious,  for  the  gravity  of  the  lesion  is  not  at  all  proportional  to 


AUSCULTATION  OF  THE  HEART.  133 

the  loudness  of  the  murmur;  indeed,  other  things  being  equal, 
loud  murmurs  are  less  serious  than  faint  ones,  provided  we  are  sure 
we  are  dealing  with  organic  lesions.  (On  the  distinction  between 
the  organic  and  functional  murmurs,  see  below,  p.  138.) 

A  loud  murmur  means  a  powerful  heart  driving  the  blood 
strongly  over  the  diseased  valve.  When  the  heart  begins  to  fail, 
the  intensity  of  the  murmur  proportionately  decreases  because  the 
blood  does  not  flow  swiftly  enough  over  the  diseased  valve  to  pro- 


nto. 83.— Mitral  Regurgitation  and  Aortic  Stenosis.    The  systolic  murmur  Is  loudest  at  the  ex- 
tremities of  the  shaded  area  and  faintest  at  its  "  waist." 

duce  as  loud  a  sound  as  formerly.  The  gradual  disappearance  of 
a  murmur  known  to  be  due  to  a  valvular  lesion  is,  therefore,  a  very 
grave  sign,  and  its  reappearance  revives  hope.  Patients  are  not 
infrequently  admitted  to  a  hospital  with  valvular  heart  trouble 
which  has  gone  on  so  long  that  the  muscle  of  the  heart  is  no  longer 
strong  enough  to  produce  a  murmur  as  it  pumps  the  blood  over  the 
diseased  valve.  In  such  a  case,  under  the  influence  of  rest  and 
cardiac  tonics,  one  may  observe  the  development  of  a  murmur  as 
the  heart  wall  regains  its  power,  and  the  louder  the  murmur  be- 
comes the  better  the  condition  of  the  patient.  On  the  other  hand, 
when  the  existence  of  a  valvular  lesion  has  been  definitely  deter- 


134    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

mined,  and  yet  the  compensation  remains  perfectly  good  (for  exam- 
ple, in  the  endocarditis  occurring  in  childi-eu  in  connection  with 
chorea) ,  an  increase  in  the  loudness  of  the  murmur  may  run  paral- 
lel with  the  advance  m  the  vahoilar  lesion. 

In  general  the  most  important  point  about  the  intensity  of  a 
murmur  is  its  Increase  or  decrease  while  under  ohsercat'ion,  and  not 
its  loudness  at  any  one  time. 

(5)  Quality  of  Heart  Murnmrs.  — It  has  been  already  mentioned 
that  the  quality  of  a  heart  murmur  is  never  anything  like  the 
sound  which  we  ordinarily  designate  by  the  word  "mui'mur."  The 
commonest  type  of  heart  murmur  has  a  blowing  quality,  whence  the 
old  name  of '^ belloics  sound."  The  sound  of  the  letter  "f"  pro- 
longed is  not  imlike  the  quality  of  certain  murmurs.  Blowing 
murmurs  may  be  low-pitched  like  the  sound  of  air  passing  through 
a  large  tube,  or  high-pitched  approaching  the  sound  of  a  whistle. 
This  last  type  merges  into  that  known  as  the  musical  murmur,  in 
which  there  is  a  definite  musical  sound  whose  pitch  can  be  identi- 
fied. Rasping  or  tearing  sounds  often  characterize  the  louder 
varieties  of  murmurs. 

Finally,  there  is  one  type  of  sound  which,  though  included 
under  the  general  name  murmur,  differs  entii-ely  from  any  of  the 
other  sounds  just  described.  This  is  the  ^^presystolic  roll, "  which 
has  a  rumbling  or  blubbering  quality  or  may  remind  one  of  a  short 
drum-roll.  This  murmur  is  always  presystolic  in  time  and  usually 
associated  with  obstruction  at  the  mitral  or  tricuspid  valves.  Not 
infrequently  some  part  of  a  cardiac  murmur  will  have  a  musical 
quality  while  the  rest  is  simply  blowing  or  rasping  in  character. 
Musical  murmurs  do  not  give  us  evidence  either  of  an  especially 
serious  or  especially  mild  type  of  disease.  Their  chief  importance 
consists  in  the  fact  that  they  rarely  exist  without  some  valve 
lesion,'  and  are,  therefore,  of  use  in  excluding  the  type  of  mur- 
mur known  as  "functional,"  presently  to  be  discussed,  and  not 
due  to  valve  disease.  Very  often  rasping  murmurs  are  associated 
either  with  the  calcareous  deposit  upon  a  valve  or  very  marked 
narrowing  of  the  valve  orifice. 

'  Rosenbach  holds  that  they  may  be  produced  by  adhesive  pericarditis. 


AUSCULTATION  OF  THE  HEART,  135 

Murmurs  may  be  accented  at  the  beginning  or  the  end ;  that  is, 
they  may  be  of  the  crescendo  type,  growing  louder  toward  the  end, 
or  of  the  decrescendo  type  with  their  maximum  intensity  at  the 
beginning.  Almost  all  murmurs  are  of  the  latter  type  except  those 
associated  with  mitral  or  tricuspid  obstruction. 

(6)  Letujth  of  2Iarmurs. — Murmurs  may  occupy  the  whole 
of  systole,  the  whole  of  diastole,  or  only  a  portion  of  one  of 
these  periods,  but  no  conclusions  can  be  drawn  as  to  the  severity 
of  the  valve  lesion  from  the  length  of  the  murmur.  A  short  mur- 
mur, especially  if  diastolic,  may  be  of  very  serious  prognostic  im- 
port. 

(7)  Relations  to  the  Normal  Sounds  of  the  Heart. — Cardiac  mur- 
murs may  or  may  not  replace  the  normal  heart  sounds.  They  may 
occur  simultaneously  with  one  or  both  sounds  or  between  the 
sounds.  These  facts  have  a  certain  amount  of  significance  in  prog- 
nosis. Murmurs  which  entirely  replace  cardiac  sounds  usually  mean 
a  severer  disease  of  the  affected  valve  than  murmurs  which  accom- 
pany, but  do  not  replace,  the  normal  heart  sounds.  Post-systolic 
or  late  systolic  murmurs,  which  occur  between  the  first  and  the 
second  soimd,  are  usually  associated  with  a  relatively  slight  degree 
of  valvular  disease.  Late  diastolic  murmurs,  on  the  other  hand, 
have  no  such  favorable  significance. 

(8)  Effects  of  Position,  Exercise,  and  Respiration  upon  Cardiac 
JIurmurs. — Almost  all  cardiac  murmurs  are  affected  to  a  greater 
or  less  extent  by  the  position  which  the  patient  assumes  while  he 
is  examined.  Systolic  murmurs  which  are  inaudible  while  the 
patient  is  in  a  sitting  or  standing  position  may  be  quite  easily 
heard  when  the  patient  lies  down.  On  the  other  hand,  a  pre- 
systolic roll  which  is  easily  heard  Avhen  the  patient  is  sitting  up 
may  entirely  disappear  when  he  lies  down.  Diastolic  murmurs 
are  relatively  little  affected  by  the  position  of  the  patient,  but 
in  the  majority  of  cases  are  somewhat  louder  in  the  upright  posi- 
tion. 

The  effects  of  exercise  may  perhaps  be  fitly  mentioned  here. 
Feeble  murmurs  may  altogether  disappear  Avhen  the  patient  is  at 
rest,  and  under  such  circumstances  may  be  made  easily  audible  by 


136    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

getting  the  patient  to  walk  briskly  up  and  down  the  room  a  few 
times.  Such  lesions  are  usually  comparatively  slight.'  On  the 
other  hand,  murmurs  which  become  more  marked  as  a  result  of  rest 
are  generally  of  the  severest  type  (see  above,  p.  132). 

Organic  murmurs  are  usually  better  heard  at  the  end  of  expira- 
tion and  become  fainter  during  inspiration  as  the  expanding  lung 
covers  the  heart.  This  is  especially  true  of  those  produced  at  the 
mitral  valve,  and  is  in  marked  contrast  with  the  variations  of  func- 
tional murmurs  which  are  heard  chiefly  or  exclusively  at  the  end  of 
inspiration. 

(9)  Sudden  Metamorphosis  of  Murmurs. — In  acute  endocarditis, 
when  vegetations  are  rapidly  forming  and  changing  their  shape 
upon  the  valves,  murmurs  may  appear  and  disappear  very  sud- 
denly. This  metamorphosing  character  of  cardiac  murmurs,  when 
taken  in  connection  with  other  physical  signs,  may  be  a  very  im- 
portant factor  in  the  diagnosis  of  acute  endocarditis.  In  a  similar 
way  relaxation  or  rupture  of  one  of  the  tendinous  cords,  occurring 
in  the  course  of  acute  endocarditis,  may  effect  a  very  sudden  change 
in  the  auscultatory  phenomena. 

"  Functional  Murmurs. " 

Not  every  murmur  which  is  to  be  heard  over  the  heart  points  to 
disease  either  in  the  valves  or  in  the  orifices  of  the  heart.  Perhaps 
the  majority  of  all  murmurs  are  thus  unassociated  with  vahiilar 
disease,  and  to  such  the  name  of  "accidental,"  "functional,"  or 
"  haemic  "  murmurs  has  been  given.  The  origin  of  these  "  functional " 
murmurs  has  given  rise  to  an  immense  amount  of  controversy,  and 
it  cannot  be  said  that  any  one  explanation  is  now  generally  agreed 
upon.  To  me  the  most  plausible  view  is  that  which  regards  most 
of  them  as  due  either  to  a  temporary  or  permanent  dilatation  of 
the  conus  arteriosus,  or  to  pressure  or  suction  exerted  upon  the 
overlapping  lung  margins  by  the  cardiac  contractions.  This  ex- 
plains only  the  systolic  functional  murmurs,  which  make  up  ninety- 
nine  per  cent,  of  all  functional  murmurs.  The  diastolic  functional 
murmurs,  which  undoubtedly  occur,  although  with  exceeding  rarity, 
'  For  exception  to  this  see  below,  page  101. 


AUSCULTATION  OF  THE  HEART.  137 

are  jDi-obably  due  to  sounds  produced  in  the  veins  of  the  neck  and 
transmitted  to  the  innominate  or  vena  cava. 

Characteristics  of  Functional  Miwmurs. — (1)  Almost  all  func- 
tional murmurs  are  systolic,  as  has  before  been  mentioned. 

(2)  The  vast  majority  of  them  are  heard  best  over  the  pulmonic 
valve  in  the  second  left  intercostal  space.  From  this  point  they 
are  transmitted  in  all  directions,  and  are  frequently  to  be  heard,  al- 
though with  less  intensity,  in  the  aortic  and  mitral  areas.  Occa- 
sionally they  may  have  their  maximum  intensity  in  one  of  the  latter 
positions. 

(3)  As  a  rule,  they  are  very  soft  and  blowing  in  quality,  though 
exceptionally  they  may  be  loud  and  rough. 

(4)  They  are  not  associated  with  any  evidence  of  enlargement 
of  the  heart  nor  with  accentuation  of  the  pulmonic  second  sound.' 

(5)  They  are  usually  louder  at  the  end  of  inspiration. 

(6)  They  are  usually  heard  over  a  very  limited  area  and  not 
transmitted  to  the  left  axilla  or  to  the  back. 

(7)  They  are  especially  evanescent  in  character;  for  example, 
they  may  appear  at  the  end  of  a  hard  run  or  boat  race  or  during 
an  attack  of  fever,  and  disappear  within  a  few  days  or  hours.  Res- 
piration, position,  and  exercise  produce  greater  variations  in  them 
than  in  "  organic  "  murmurs. 

(8)  They  are  especially  apt  to  be  associated  with  anceniia, 
although  the  connection  between  anaemia  and  functional  heart  mur- 
murs is  by  no  means  as  close  as  has  often  been  supposed.  The 
severest  types  of  ansemia,  for  example  pernicioiis  anaemia,  may  not 
be  accompanied  by  any  murmur,  while,  on  the  other  hand,  typical 
functional  murmurs  are  often  heard  in  patients  whose  blood  is  nor- 
mal, and  even  in  full  health.  It  should  not  be  forgotten  that  a 
real,  though  temporary,  leakage  through  the  mitral  or  tricuspid 
valve  may  be  associated  with  ansemia  or  debilitated  conditions 
owing  to  weakening  of  the  papillary  muscles  or  of  the  mitral 
sphincter.     In  such  cases  we  find  not  the  signs  of  a  functional 

'  In  chlorosis  the  second  pulmonic  sound  is  often  very  loud  (owing  to  the 
retraction  of  the  lungs  and  uncovering  of  the  conns  arteriosus)  and  associated 
with  a  systolic  murmur. 


138    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

murmur,  as  above  described,  but  the  evidence  of  an  organic  valve 
lesion  hereafter  to  be  described. 

The  distinctions  between  organic  and  functional  heart  murmurs 
may  be  summed  up  as  follows : 

Orfjanlc  murmurs  may  occu^Dy  any  part  of  the  cardiac  cycle;  if 
systolic,  they  are  usually  transmitted  either  into  the  axilla  and 
back  or  into  the  great  vessels  of  the  neck ;  they  are  usually  asso- 
ciated with  evidences  of  cardiac  enlargement  and  changes  in  the  sec- 
ond sounds  at  the  base  of  the  heart,  as  well  as  with  signs  and  symp- 
toms of  stasis  in  other  organs.  Organic  murmurs  not  infrequently 
have  a  musical  or  rasping  quality,  although  this  is  by  no  means  al- 
ways the  case.  They  are  rarely  loudest  in  the  pulmonic  area  and 
are  relatively  uninfluenced  by  respiration,  position,  or  exercise. 

Functional  murmurs  are  almost  always  systolic  in  time  and 
usually  heard  with  maximum  intensity  in  the  pulmonic  area.  They 
are  rarely  transmitted  beyond  the  precordial  region  and  are  usually 
loudest  at  the  end  of  inspiration.  They  are  not  accompanied  by 
evidences  of  cardiac  enlargement  or  pathological  accentuation  of 
the  second  sounds  at  the  base  of  the  heart,  nor  by  signs  of  venous 
stasis  or  dropsy.  They  are  very  apt  to  be  associated  with  anaemia 
or  with  some  special  attack  upon  the  resources  of  the  body  {e.g., 
physical  overstrain  or  fever),  and  to  disappear  when  such  forces  are 
removed.  They  are  usually  soft  in  quality;  never  musical.  The 
very  rare  diastolic  functional  murmur  occurs  exclusively,  so  far  as 
I  am  aware,  in  conditions  of  profoimd  anaemia;  i.e.,  when  the  haemo- 
globin is  twenty -five  per  cent  or  less.  It  can  be  abolished  by  press- 
ure upon  the  bulbus  jugularis,  and  can  be  observed,  if  followed  up 
into  the  neck,  to  pass  over  gradually  into  a  continuous  venous  hum 
with  a  diastolic  accent. 

Cardio- Respiratory  Murmurs. 

When  a  portion  of  the  free  margin  of  the  lung  is  fixed  by  ad- 
hesions in  a  position  overlapping  the  heart,  the  cardiac  movements 
may  rhythmically  displace  the  air  in  such  piece  of  lung  so  as  to 
give  rise  to  sounds  which  at  times  closely  simulate  cardiac  mur- 
murs.    These  conditions  are  most  often  to  be  found  in  the  tongue- 


AUSCULTATION  OF  THE  HEART.  139 

like  projection  of  the  left  lung,  which  normally  overlaps  the  heart, 
but  it  is  probably  the  case  that  cardio-respiratory  murmurs  may  be 
produced  without  any  adhesion  of  the  lung  to  the  pericardium 
under  conditions  not  at  j^resent  understood.  Such  murmurs  may 
be  heard  under  the  left  clavicle  or  below  the  angle  of  the  left  scap- 
ula, as  well  as  near  the  apex  of  the  heart, — less  often  in  other  parts 
of  the  chest. 

Cardio-respiratory  murmurs  may  be  either  systolic  or  diastolic, 
but  the  vast  majority  of  cases  are  systolic.  The  area  over  which 
they  are  audible  is  usually  a  very  limited  one.  They  are  greatly 
affected  by  position  and  by  respiration,  and  are  heard  most  distinctly 
if  not  exclusively  during  inspiration,  especially  at  the  end  of  that 
act.  (This  fact  is  an  important  aid  in  distinguishing  them  from 
true  cardiac  murmurs,  which  are  almost  always  fainter  at  the  end 
of  mspiration.)  They  are  also  greatly  affected  by  cough  or  forced 
respiration  or  by  holding  the  breath,  whereas  cardiac  murmurs 
are  relatively  little  changed  thereby.  Pressure  on  the  outside 
of  the  thorax  and  in  their  vicinity  may  greatly  modify  their  in- 
tensity or  quality,  while  organic  cardiac  murmurs  are  but  little 
influenced  by  pressure.  As  a  rule,  they  have  the  quality  of  nor- 
mal respiratory  murmur,  and  sound  like  an  inspiration  interrupted 
by  each  diastole  of  the  heart. 

In  case  the  effect  of  the  cardiac  movements  is  exerted  upon  a 
piece  of  lung  in  which  a  catarrhal  process  is  going  on,  we  may  have 
systolic  or  diastolic  explosions  of  rales,  or  any  type  of  respiratory 
murmur  except  the  bronchial  type,  since  this  is  prodiiced  in  solid  lung 
which  could  not  be  emptied  or  filled  under  the  influence  of  the  car- 
diac movements.  Cardio-respiratory  murmurs  have  no  special  diag- 
nostic significance,  and  are  mentioned  here  only  on  accoimt  of  the  im- 
portance of  not  confusing  them  with  true  cardiac  murmurs.  They 
were  formerly  thought  to  indicate  phthisis,  but  such  is  not  the  case. 

MurrMirs  of  Venous  Origin. 

I  have  already  mentioned  that  the  venous  hum  so  often  heard 
in  the  neck  in  cases  of  anaemia  may  be  transmitted  to  the  region  of 
the  base  of  the  heart  and  heard  there  as  a  diastolic  murmur  owing 


140    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

to  the  acceleration  of  the  venous  current  by  the  aspiration  of  the 
right  ventricle  during  diastole.  Such  murmurs  are  very  rare  and 
may  usually  be  obliterated  by  pressure  upon  the  bulbus  jugularis, 
or  even  by  the  compression  brought  to  bear  upon  the  vems  of  the 
neck  when  the  head  is  sharply  turned  to  one  side.  They  are  heard 
better  in  the  upright  position  and  during  inspiration. 

Arterial  Murmurs. 

(1)  Roughening  of  the  arch  of  the  aorta,  due  to  chronic  endo- 
carditis, is  a  frequent  cause  in  elderly  men  of  a  systolic  murmur, 
heard  best  at  the  base  of  the  heart  and  transmitted  into  the  vessels 
of  the  neck.  Such  a  murmur  is  sometimes  accompanied  by  a  pal- 
pable thrill.  From  cardiac  murmurs  it  is  distinguished  by  the  lack 
of  any  other  evidence  of  cardiac  disease  and  the  presence  of  marked 
arterio-sclerosis  in  the  peripheral  vessels  (see  further  discussion 
imder  Aortic  Stenosis,  p.  180,  and  under  Aneurism,  p.  220) . 

(2)  A  narrowing  of  the  Imnen  of  the  left  subclavian  artery,  due 
to  some  abnormality  in  its  course,  may  give  rise  to  a  systolic  mur- 
mur heard  close  below  the  left  claWcle  at  its  outer  end.  The  mur- 
mur is  greatly  influenced  by  movements  of  the  arm  and  esjDecially 
by  respiratory  movements.  During  inspiration  it  is  much  louder, 
and  at  the  end  of  a  forced  expiration  it  may  disappear  altogether. 
Occasionally  such  murmurs  are  transmitted  through  the  clavicle  so 
as  to  be  audible  above  it. 

(3)  Pressure  exerted  upon  any  of  the  superficial  arteries  (carot- 
id, femoral,  etc.)  produces  a  systolic  murmur  (see  below,  p.  178). 
Diastolic  arterial  murmurs  are  peculiar  to  aortic  regurgitation. 

(4)  Over  the  anterior  fontanelle  in  infants  and  over  the  gra\dd 
uterus  systolic  murmurs  are  to  be  heard  which  are  probably  arterial 
in  origin. 


PART  II. 

DISEASES    OF    THE    HEART. 


CHAPTEE  VII. 

VALVULAR  LESIONS. 

Clinically  it  is  convenient  to  divide  the  ills  whicli  befall  the 
heart  into  three  classes : 

(1)  Those  which  deform  the  cardiac  valves  (valvular  lesions). 

(2)  Those  which  weaken  the  heart  wall  (parietal  disease). 

(3)  Congenital  malformations. 

Lesions  which  alfect  the  cardiac  valves  without  deforming  them 
are  not  often  recognizable  during  life.  The  vegetations  of  acute 
endocarditis'  do  not  usually  produce  any  peculiar  physical  signs 
until  they  have  so  far  deformed  or  obstructed  the  valves  as  to  pre- 
vent their  opening  or  closing  properly. 

The  murmurs  which  are  often  heard  over  the  heart  in  cases  of 
acute  articular  rheumatism  cannot  be  considered  as  evidence  of 
vegetative  endocarditis  unless  valvular  deformities,  and  their  re- 
sults in  valvular  obstruction  or  incompetency,  ensue.  The  chordae 
tendinese  may  be  ruptured  or  shortened,  thickened,  and  welded  to- 
gether into  shapeless  masses,  but  if  these  deformities  do  not  affect 
the  action  of  the  valves  we  have  no  means  of  recognizing  them  dur- 
mg  life.  Congenital  malformations  are  practically  unrecognizable 
as  such.  If  they  do  not  affect  the  valves,  we  cannot  with  any  cer- 
tainty make  out  what  is  wrong. 

For  physical  diagnosis,  then,  heart  disease  means  either  de- 
formed valves  or  weakened  walls.  Whatever  else  may  exist,  we 
are  none  the  wiser  for  it  unless  the  aiitopsy  enlightens  us. 

'  See  Appendix. 


142    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

In  this  chapter  I  shall  confine  myself  to  the  discussion  of  vah-u- 
lar  lesions  and  their  results. 

Valvular  lesions  are  of  two  types : 

(a)  Those  which  produce  partial  obstruction  of  a  valve  orifice 
or  prevent  its  opening  fully  {"stenosis  "). 


1  ConH«~artQrio«UH 


,  potterlor  aortao 


ValTulM 
Iriona- 
pid»l!< 


i'lG.  84.~Tlie  Base  of  the  Contracted  Heart  Showing  Sphincteric  Action  of  the  Muscular  Fibres 
Surrounding  the  Mitral  and  Tricuspid  Valves.  The  outer  dotted  line  is  ths  outline  of  the 
relaxed  heart.  The  inner  dotted  circles  show  the  size  of  the  mitral  and  tricuspid  valves 
during  diastole,  a.  Outline  of  the  heart  when  relaxed ;  h,  outline  of  the  relaxed  tricuspid 
valve ;  c,  outline  of  the  mitral  orifice  during  diastole. 


(b)  Those  which  produce  leakage  through  a  valve  orifice  or 
prevent  its  closing  effectively  {"regurgitation,"  " insufficiencu," 
"  incompetenci/  ") . 

.     Stenosis  results  always  from  the  stiffening,  thickening,  and  con- 
traction of  a  valve. 

Regurgitation,  on  the  other  hand,  may  be  the  result  either  of — 


VALVULAR  LESIONS. 


143 


Mitral  curtains. 


(a)  Deformity  of  a  valve,  or 

(h)  Weakening  of  the  heart  muscle. 

The  mitral  and  tricuspid  orifices  are  closed  not  simply  by  the 
shutting  of  their  valves,  but  also  in  part  by  the  sphincter-like  ac- 
tion of  the  circular  fibres  of  the  heart  wall  (see  Fig.  84)  and  the 
contraction  of  the  papillary  muscles  (Fig.  85). 

In  birds  the  tricuspid  orifice  has  no  valve  and  is  closed  wholly 
by  the  muscular  sphincter  of 
the  heart  wall. 

In  conditions  of  acute  car- 
diac failure,  such  as  may  oc- 
cur after    a    hard    run,    the 
papillary  muscles  are  in    all 
probability     relaxed, 
so  that  the  valve -flaps 
swing  back   into  the 
auricle  and  permit  re- 
gurgitation of   blood 
from  the  ventricle. 

Valviilar  incom- 
petence, then,  differs  from 
valvidar  ohstniction  in  that 
the  latter  always  involves 
deformity  and  stiffening  of 
valves,  while  incomi^etence 
or  leakage  is  often  the  result 
of  deficient   muscular   action 

on  the  part  of  the  heart  wall.  An  obstructed  valve  is  almost  always 
leaky  as  well,  since  the  same  deformities  which  prevent  a  valve 
from  opening  usually  prevent  its  closure;  hut  this  ride  does  not 
work  hockivard.  A  leaky  valve  is  often  not  obstructed.  It  is  leaky 
but  not  obstructed  if  the  valve  curtain  has  been  practically  de- 
sti-oyed  by  endocarditis;  or,  again,  it  is  leaky  but  not  obstructed  if 
the  leak  represents  muscular  weakening  of  the  mitral  sphincter  ^or 
of  the  papillary  muscles.  Pure  stenosis  is  very  rare.  Pure  regur- 
gitation is  very  common. 


Chord  ea 
tendlneae. 


Papillary 
muscle. 


Myocardium. 


Pericardium. 


Fig.  8-'). -The  Mitral  Valve  Closed,  Showing  the 
Action  of  the  Papillary  Muscles. 


144    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

When  valves  are  so  deformed  that  their  orifice  is  both  leaky  and 
obstructed,  we  have  what  is  known  as  a  "  combined  "  or  "  double  " 
valve  lesion. 

Since  valvular  lesions  are  recognized  largely  by  their  resultSf 
first  upon  the  walls  of  the  heart  itself  and  then  upon  the  other 
organs  of  the  body,  it  seems  best  to  give  some  account  of  these 
results  before  passing  on  to  the  description  of  the  individual  le- 
sions in  the  heart  itself. 

The  results  of  vahailar  lesions  are  first  conservative  and  later 
destructive.     The  conservative  results  are  known  as : 

The  establishment  of  covvpensation  through  hypeHrophy. 

The  destructive  or  degenerative  results  are  known  as : 

The  failure  of  com2jensation  through  {or  without')  dilatation. 

I  shall  consider,  then, 

(a)  The  establishment  and  the  failure  of  compensation. 

(i)  Cardiac  hypertrophy. 

(c)  Cardiac  dilatation. 

ESTABLISHMENT     AND     FAILURE     OF     COMPENSATION     IN 
VALVULAR   DISEASE   OF  THE   HEART. 

We  may  discriminate  three  periods  in  the  progress  of  a  case  of 
vahiilar  heart  disease : 

(1)  The  period  before  the  establishment  of  compensation. 

(2)  The  period  of  compensation. 

(3)  The  period  of  failing  or  ruptured  compensation. 

(1)    Compensation  Not   Yet  Established. 

In  most  cases  of  acute  val\'ular  endocarditis,  whether  of  the 
relatively  benign  or  of  the  malignant  type,  there  is  a  time  when 
the  lesion  is  perfectly  recognizable  despite  the  fact  that  compensa- 
tory hypertrophy  has  not  yet  occurred.  In  some  cases  this  period 
may  last  for  months ;  the  heart  is  not  enlarged,  there  is  no  a,ccentu- 
ation  of  either  second  sound  at  the  base,  there  is  no  venous  stasis, 
and  our  diagnosis  must  rest  solely  upon  the  presence  and  character- 
istics of  the  murmur.     For  example,  in  early  cases  of  mitral  regur- 


VALVULAR  LESIONS.  145 

gitation  due  to  chorea  or  rheumatism,  the  disease  may  be  recog- 
nized by  the  presence  of  a  loud  musical  murmur  heard  in  the  back 
as  well  as  at  the  apex  and  in  the  axilla.  In  the  earlier  stages  of 
aortic  regurgitation  occurring  in  young  people  as  a  complication  of 
rheumatic  fever,  there  may  be  absolutely  no  evidence  of  the  valve 
lesion  except  the  characteristic  diastolic  murmur.  In  most  text- 
books of  physical  diagnosis  I  think  too  little  attention  is  given  to 
this  stage  of  the  disease. 

(2)   The  Period  of  Compensation. 

Valvular  disease  would,  hoAvever,  soon  prove  fatal  were  it  not 
for  the  occurrence  of  compensatory  hypertrophy  of  the  heart  walls. 
To  a  certam  extent  the  heart  contracts  as  a  single  muscle,  and  in- 
creases the  size  of  all  its  walls  in  response  to  the  demand  for  in- 
creased work ;  but  as  a  rule  the  hypertrophy  affects  especially  one 
ventricle — that  ventricle,  namely,  upon  which  especially  demand  is 
made  for  mcreased  power  in  order  to  overcome  an  increased  resist- 
ance in  the  vascular  circuit  which  it  supplies  with  blood.  What- 
ever increases  the  resistance  in  the  lungs  brings  increased  work 
upon  the  right  ventricle ;  whatever  increases  the  resistance  in  the 
aorta  or  peripheral  arteries  increases  the  amount  of  work  which  the 
left  ventricle  must  do. 

Now,  any  disease  of  the  mitral  valve,  whether  obstruction  or 
leakage,  results  in  engorgement  of  the  lungs  with  blood,  and  hence 
demands  an  increased  amount  of  work  on  the  part  of  the  right 
ventricle  in  order  to  force  the  blood  through  the  overcrowded  pul- 
monary vessels ;  hence  it  is  in  mitral  disease  that  we  find  the  great- 
est compensatory  hypertrophy  of  the  right  ventricle. 

On  the  other  hand,  it  is  obvious  that  obstruction  at  the  aortic 
valves  or  in  the  peripheral  arteries  (arterio-sclerosis)  demands  an 
increase  in  power  in  the  left  ventricle,  in  order  that  the  requisite 
amount  of  blood  may  be  forced  through  arteries  of  reduced  calibre, 
while  if  the  aortic  valve  is  so  diseased  that  a  part  of  the  blood 
thrown  into  the  aorta  by  the  left  ventricle  returns  into  that  ven- 
tricle, its  work  is  thereby  greatly  increased,  since  it  has  to  contract 
upon  a  larger  volume  of  blood. 
10 


146    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

In  response  to  these  demands  for  increased  work,  the  muscular 
wall  of  the  left  ventricle  increases  in  thickness,  and  compensation  is 
thus  established  at  the  cost  of  an  increased  amount  of  work  on  the 
part  of  the  heart. ' 

(3)  Failure  of  Compensation. 

Sooner  or  later  in  the  vast  majority  of  cases  the  heart,  handi- 
capped as  it  is  by  a  leakage  or  obstruction  of  one  or  more  valves, 
becomes  unable  to  meet  the  demands  made  upon  it  by  the  needs  of 
the  circulation.  Failure  of  comjjensation  is  sometimes  associated 
with  dilatation  of  the  heart  and  weakening  of  its  walls,  but  in 
many  cases  no  such  change  can  be  found  to  account  for  its  failure, 
and  we  have  to  fall  back  upon  changes  in  the  nutrition  of  the 
heart  wall  or  upon  some  hypothetical  derangement  of  the  ner- 
vous mechanism  of  the  organ  as  an  explanation.  ^Miatever  the 
cause  may  be,  the  result  of  ruptured  compensation  is  venous  stasis  ; 
that  is,  oedema  or  dropsy  of  various  organs  appears.  If  the 
left  ventricle  is  especially  weakened,  dropsy  appears  first  in  the 
legs,  on  account  of  the  influence  of  gravity,  soon  after  in  the  geni- 
tals, lungs,  liver,  and  the  serous  cavities.  Engorgement  of  the 
lungs  is  especially  marked  in  cases  of  mitral  disease  with  weakening 
of  the  right  ventricle,  and  is  manifested  by  dyspnoea,  cyanosis, 
cough,  and  haemoptysis.  In  many  cases,  hoAvever,  dropsy  is  very 
irregularly  and  unaccountably  distributed,  and  does  not  follow  the 
rules  just  given.  In  pure  aortic  disease,  uncomplicated  by  leakage 
of  the  mitral  valve,  dropsy  is  a  relatively  late  symptom,  and  dysp- 
noea and  precordial  pain  (angina  pectoris)  are  more  prominent. 

HYPERTROPHY  AND  DILATATION. 

Since  cardiac  hypertrophy  or  dilatation  are  not  in  themseh^es 
diseases,  but  may  occur  in  any  disease  of  the  heart  (vahiilar  or 
parietal),  it  seems  best  to  give  some  account  of  them  and  of  the 
methods  by  which  they  may  be  recognized,  before  taking  up  sepa- 
rately the  different  lesions  Avith  which  they  are  associated. 

'  Rosenbach  brings  forward  evidence  to  show  that  the  arteries,  the  lungs. 
and  other  organs  actively  assist  in  maintaining  compensation. 


VALVULAR  LESIONS.  147 

1.    Cardiac  Hypertrophy. 

Hypertrophy  of  the  heart  is  usually  due  to  the  following  causes : 

First  (aud  most  frequeut) :  Yahiilar  disease  of  the  heart  itself. 
Second:  Obstruction  of  the  flow  of  blood  through  the  arteries 
owing  to  increase  of  arterial  resistance,  such  as  occurs  in  chronic 
nephritis  and  arterio-sclerosis.  Third :  Obstruction  to  the  circula- 
tion of  the  blood  through  the  lungs  (emphysema,  cirrhosis  of  the 
lung,  fibroid  phthisis).  Fourth:  Severe  and  prolonged  muscular 
exertion  (athlete's  heart). 

In  valvular  disease  the  greatest  degree  of  hypertrophy  is  to  be 
seen  usually  in  relatively  young  persons,  and  especially  when  the 
advance  of  the  lesion  is  not  very  rapid. 

Hypertrophy  of  the  heart  in  vahailar  disease  is  also  influenced 
by  the  amount  of  muscular  work  done  by  the  patient,  by  the  de- 
gree of  vascular  tension,  and  by  the  treatment.  In  the  great  major- 
ity of  cases  of  hypertrophy,  from  whatever  cause,  both  sides  of  the 
heart  are  affected,  but  we  may  distinguish  cases  in  which  one  or  the 
other  ventricle  is  predominantly  affected. 

(1)  Cardiac  hypertrophT)  affecting  esptecially  the  left  ventricle. 

(a)  The  apex  impulse  is  usually  lower  than  normal,  often  in 
the  sixth  space,  occasionally  in  the  seventh. or  eighth.'  It  is  also 
farther  to  the  left  than  normal,  but  far  less  so  than  in  cases  in 
which  the  hypertrophy  affects  especially  the  right  ventricle.  The 
area  of  visible  pulsation  is  usually  increased,  and  a  considerable  por- 
tion of  the  chest  wall  may  be  seen  to  move  with  each  systole  of  the 
heart,  while  frequently  there  is  a  systolic  retraction  of  the  inter- 
spaces in  place  of  a  systolic  impulse. 

(b)  Palpation  confirms  the  results  of  inspection  and  shows  us 
also  that  the  apex  impulse  is  unusually  powerful.  Percussion 
shows  in  many  cases  that  the  cardiac  dulness  is  more  intense  and 
its  area  increased  downward  and  to  a  lesser  extent  toward  the  left.* 

'  This  is  due  partly  to  a  stretching  of  the  aorta,  produced  by  the  increased 
weight  of  the  lieart. 

-Post  mortem  hypertrophy  of  the  left  ventricle  is  often  found  despite  the 
absence  of  the  above  signs  in  life. 


148    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

(c)  If  we  listen  iii  the  region  of  the  maximum  cardiac  impulse, 
we  generally  hear  an  unusually  long  and  low-pitched  first  sound, 
which  may  or  may  not  be  of  a  greater  intensity  than  normal.  A 
very  loud  first  sound  is  much  more  characteristic  of  a  cardiac  neu- 
rosis than  of  pure  hypertrophy  of  the  left  ventricle. 

The  second  sound  at  the  apex  (the  aortic  second  sound  trans- 
mitted) is  usually  much  louder  and  sharper  than  usual.  Ausculta- 
tion in  the  aortic  area  shows  that  the  second  sound  at  that  point  is 
loud  and  ringing  in  character.  Not  infrequently  the  jjeripheral  ar- 
teries (the  subclavians,  brachials,  carotids,  radials,  and  femorals) 
may  be  seen  to  pulsate  with  each  systole  of  the  heart.  This  sign  is 
most  frequently  observed  in  cases  of  hypertrophy  of  the  left  ven- 
tricle, which  are  due  to  aortic  regurgitation,  but  is  by  no  means 
peculiar  to  this  disease  and  may  be  repeatedly  observed  when  the 
cardiac  hypertrophy  is  due  to  nephritis  or  muscular  work.  I  have 
frequently  observed  it  in  athletes,  blacksmiths,  and  others  Avhose 
muscular  work  is  severe. 

The  radial  pulse  wave  has  no  constant  characteristics,  but  de- 
pends rather  upon  the  cause  which  has  produced  the  hj-pertrophy 
than  upon  the  hypertrophy  itself. 

(2)   Cardiac  HijiieHrophy  Affecting  Especially  the  Right   Ventricle. 

It  is  much  more  difficult  to  be  certain  of  the  existence  of  en- 
largement of  the  right  ventricle  than  of  the  left.  Practically  we 
have  but  two  reliable  physical  signs : 

(o)  Increase  in  the  transverse  diameter  of  the  heart,  as  shown 
by  the  position  of  the  ai>ex  impulse  and  by  percussion  of  the  right 
and  left  borders  of  the  heart ;  and 

(b)  Accentuation  of  the  pulmonic  second  sound,  which  is  often 
palpable  as  well  as  audible. 

The  apex  beat  is  displaced  both  to  the  left  and  downward,  hut 
especially  to  the  left.  In  cases  of  long-standing  mitral  disease,  the 
cardiac  impulse  may  be  felt  in  mid-axilla,  several  inches  outside  the 
nipple,  and  yet  not  lower  down  than  the  sixth  intercostal  space. 
In  a  small  percentage  of  cases  (i.e.,  when  the  right  auricle  is  en- 
gorged), an  increased  area  of  dulness  to  the  right  of  the  sternum 


VALVULAR  LESIONS.  149 

may  be  demonstrated.  Accentuation  of  the  pulmonic  second  sound 
is  almost  invariably  present  in  hypertrophy  of  the  right  ventricle, 
though  it  is  not  peculiar  to  that  condition.  It  may  be  heard,  for 
example,  in  eases  of  pneumonia  when  no  such  hypertrophy  is  pres- 
ent, but  in  the  vast  majority  of  cases  of  cardiac  disease  we  may 
infer  the  presence  and  to  some  extent  the  amount  of  hyjjertrophy 
of  the  right  ventricle  from  the  presence  of  a  greater  or  lesser  ac- 
centuation of  the  pulmonic  second  sound.  The  radial  pulse  shows 
nothing  characteristic  of  this  type  of  hypertrojjhy. 

Epigastric  pulsation  gives  us  no  evidence  of  the  existence  of 
hypertrophy  of  the  right  ventricle,  despite  contrary  statements  in 
many  text-books.  Such  pulsation  is  frequently  to  be  seen  in  per- 
sons with  normal  hearts,  and  is  frequently  absent  when  the  right 
ventricle  is  obviously  hypertrophied.  It  is  perhajjs  most  often  due 
to  an  unusually  low  position  of  the  whole  heart. 

Dilatation  of  the   Heart. 

(1)  Acute  Dilatation. — Immediately  after  severe  muscular  exer- 
tion, as,  for  examj)le,  at  the  finish  of  a  boat  race,  or  of  a  two-mile 
i-un  (especially  in  persons  not  properly  trained),  an  acute  dilatation 
of  the  heart  may  occur,  and  in  debilitated  or  poorly  nourished  sub- 
jects such  an  acute  dilatation  may  be  serious  or  even  fatal  in  its 
results. 

(2)  Chronic  dilatation  comes  on  gradually  as  a  result  of  valvu- 
lar disease  or  other  cause,  and  gives  rise  to  practically  the  same 
physical  signs  as  those  of  acute  dilatation,  from  which  it  differs 
chiefly  as  regards  the  accompanying  physical  phenomena  and  the 
prognosis.  Briefly  stated,  the  signs  of  dilatation  of  the  heart, 
whether  acute  or  chronic,  are : 

(«)  Feebleness  and  irregularity  of  the  apex  impulse  and  of  the 
radial  impulse,  (b)  enlargement  of  the  heart,  as  indicated  by  inspec- 
tion, palpation,  and  percussion,  and  (sometimes)  (c)  mnrrnurs  indi- 
cative of  stretching  of  one  or  another  of  the  valvular  orifices. 


150    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

Dilatation  of  the  Left  Ventricle. 

Inspection  shows  little  that  is  not  better  brought  out  by  palpa- 
tion. Palpation  reveals  a  feeble  "flapping"  cardiac  impulse,  or 
a  vague  shock  displaced  both  downward  and  to  the  left  and  diffused 
over  an  abnormally  large  area  of  the  chest  wall.  Percussion  veri- 
fies the  position  of  the  cardiac  impulse  and  sometimes  shows  an 
unusually  blunt  or  rounded  outline  at  the  apex  of  the  heart. 

On  auscultation,  the  first  sound  is  usually  very  short  and  sharp, 
but  not  feehle  unless  it  is  accompanied  by  a  murmur.  In  case  the 
mitral  orifice  is  so  stretched  as  to  render  the  valve  incompetent,  or 
in  case  the  muscles  of  the  heart  are  so  fatigued  and  weakened  that 
they  do  not  assist  in  closuig  the  mitral  orifice,  a  systolic  murmur  is 
to  be  heard  at  the  apex  of  the  heart.  This  murmur  is  transmitted 
to  the  axilla  and  back,  but  does  not  usually  replace  the  first  soimd 
of  the  heart.  The  aortic  second  sound,  as  heard  in  the  aortic  area 
and  at  the  apex,  is  feeble. 

Dilatation  of  the  right  ventricle  of  the  heart  is  manifested  by  an 
increase  in  the  area  of  cardiac  dubiess  to  the  right  of  the  sternum 
(corresponding  to  the  position  of  the  right  auricle),  by  feebleness  of 
the  pubuonic  second  sound  together  with  signs  of  congestion  and 
engorgement  of  the  lungs,  and  often  by  a  systolic  murmur  at  the 
tricuspid  valve;  i.e.,  at  or  near  the  root  of  the  ensiform  cartilage. 
When  this  latter  event  occurs,  one  may  have  also  systolic  j^ulsation 
in  the  jugular  veins  and  in  the  liver  (see  below,  p.  188). 

In  cases  of  acute  dilatation,  such  as  occur  in  infectious  fevers 
or  at  the  end  of  well-contested  races,  there  is  often  to  be  heard  a 
systolic  murmur  loudest  in  the  pulmonary  area  and  due  very  pos- 
sibly to  a  dilatation  of  the  conns  arteriosus. 

The  diagnosis  of  dilatation  of  the  heart  seldom  rests  entirely 
upon  physical  signs  referable  to  the  heart  itself.  In  acute  cases 
our  diagnosis  is  materially  aided  by  a  knowledge  of  the  cause, 
which  is  often  tolerably  ob\'ious.  In  chronic  cases  the  best  evi- 
dence of  dilatation  is  often  that  furnished  by  the  venous  stasis 
which  results  from  it. 


VALVULAR  LESIONS.  151 

(4)    CHRONIC   VALVULAR   DISEASE. 
I.  Mitral  Regurgitation. 

The  commonest  and  on  the  whole  the  least  serious  of  valvular 
lesions  is  incompetency  of  the  mitral.  It  results  in  most  cases 
from  the  shortening,  stiffening,  and  thickening  of  the  valve  pro- 
duced by  rheumatic  endocarditis  in  early  life.  It  is  the  lesion 
present  in  most  cases  of  chorea  (see  Figs.  86  and  87). 

Temporary  and  curable  mitral  regurgitation  may  result  from 
weakening  of  the  heart  muscle,  Avhich  normally  assists  in  closing 
the  mitral  orifice  through  the  sphincter-like  contraction  of  its  cir- 
cular fibres. 

Great  muscular  fatigue,  such  as  is  produced  by  a  hard  boat 
race,  may  result  in  a  temporary  relaxation  of  the  mitral  sphincter 
or  of  the  papillary  muscles  sufticient  to  allow  of  genuine  but  tem- 
porary and  curable  regurgitation  through  the  mitral  orifice.  In 
conditions  of  profound  nervous  debility  and  exhaustion,  similar 
weakening  of  the  cardiac  muscles  may  allow  of  a  leakage  through 
the  mitral,  which  ceases  with  the  removal  of  its  cause.  Stress  has 
recently  been  laid  upon  these  points  by  Arnold  and  by  Morton 
Prince. 

]VIitral  insufficiency  due  to  stretching  of  the  ring  into  which  the 
valve  is  inserted  occurs  not  unfrequently  as  a  result  of  dilatation 
of  the  left  ventricle,  and  is  commonly  known  as  relative  insufficiency 
of  the  mitral  valve.  The  valve  orifice  can  enlarge,  the  valve  can- 
not, and  hence  its  curtains  are  insufficient  to  fill  up  the  dilated  ori- 
fice. This  type  of  mitral  insufficiency  frequently  results  from 
aortic  regurgitation  with  the  dilatation  of  the  left  ventricle  which 
that  lesion  produces,  or  from  myocarditis,  which  weakens  the  heart 
wall  until  it  dilates  and  widens  the  mitral  orifice. 

The  results  of  any  form  of  mitral  leakage  are : 

1.  Dilatation  or  hypertrophy  of  the  left  auricle,  which  has  to 
receive  blood  both  from  the  lungs  and  through  the  leaky  mitral 
from  the  left  ventricle. 

2.  The  overfilled  left  auricle  cannot  receive  the  blood  from  the 


152    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

lungs  as  readily  as  it  should;  hence  the  blood  "backs  up"  in  the 
lungs  and  thereby  increases  the  work  which  the  right  ventricle 
must  do  in  order  to  force  the  blood  through  them.  Thus  result 
oedema  of  the  lungs,  and — 


Fig.  a;. 


'-Z}/j/:arJta(J/?/^a/ 


Fig.  86.— Normal  Heart  during  Systole.    Mitral  valve  closed ;  blood  flowing  through  the  open 
aortic  valves  into  the  aorta. 

Fig.  87.— Mitral  Regurgitation.    The  heart  is  in  systole  and  the  arrows  show  the  current  flowing 
back  in  the  left  auricle  as  well  as  forward  into  the  aorta. 


VALVULAR  LESIONS.  153 

(3)  Hypertrophy  and  dildtation  of  the  right  ventricle,  which  in 
turn  becomes  sooner  or  later  overcrowded  so  that  the  tricuspid 
valve  gives  way  and  tricuspid  leakage  occurs. 

(4)  The  capacity  for  hypertrophy  possessed  by  the  right  auricle 
is  soon  exhausted,  and  we  get  then — 

(5)  General  venous  stasis,  which  shows  itself  first  as  venous 
pulsation  in  the  jugulars  and  in  the  liver  and  later  in  the  tissues 
drained  by  the  portal  and  peripheral  veins.  This  venous  stasis  in- 
creases the  work  of  the  left  ventricle,  and  so  we  get — 

(6)  Hypertrophy  and  dilatation  of  the  left  ventncle.  Hyper- 
trophy of  the  left  ventricle  is  also  produced  by  the  increased  work 
necessary  to  mamtain  some  vestige  of  sphincter  action  at  the  leaky 
mitral  orifice,  as  well  as  by  the  labor  of  contracting  upon  the  extra 
quantity  of  blood  delivered  to  it  by  the  enlarged  left  auricle. 

At  last  the  circle  is  complete.  Every  chamber  in  the  heart  is 
enlarged,  overworked,  and  failure  is  imminent. 

Returning  now  to  the  signs  of  mitral  regurgitation,  we  shall  find 
it  most  convenient  to  consider  first  the  type  of  regurgitation  pro- 
duced by  rheumatism  and  resulting  in  thickening,  stiffening,  and 
retraction  of  the  valve. 

Physical  Signs. 

(a)  First  Stage — Prior  to  the  Establishment  of  Compensation. 

We  have  but  one  characteristic  physical  sign : 

A  systolic  murmur  heard  loudest  at  the  apex  of  the  heart,  trans- 
mitted to  the  back  (below  or  inside  the  left  scapula)  and  to  the  left 
axilla.  The  murmur  is  not  infrequently  musical  in  character,  and 
when  this  is  the  case  diagnosis  is  much  easier.  Systolic  musical 
murmurs  so  transmitted  do  not  occur  without  valvular  leakage. 
Rosenbach  believes  that  adherent  pericardium  is  capable  of  produc- 
ing such  a  murmur,  but  only,  if  I  understand  him  rightly,  in  case 
there  is  a  genuine  mitral  leakage  due  to  the  embarrassing  embrace 
of  the  pericardium  which  prevents  the  mitral  orifice  from  closing. 

"Functional"  or  "hsemic"  murmurs  are  rarely  heard  in  the 
back,  and  very  rarely,  if  ever,  have  a  musical  quality. 


154    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

Cases  of  mitral  regurgitation  are  not  very  often  seen  at  this 
stage,  but  in  acute  endocarditis  after  the  fever  and  anseniia  have 
subsided,  or  in  chorea,  such  a  murmur  may  exist  for  days  or  weeks 
before  any  accentuation  of  the  jjulmonic  second  sound  or  any  en- 
largement of  the  heart  appears.  I  have  had  the  opportunity  of 
verifying  the  diagnosis  at  autopsy  m  two  such  cases. 

(b)  Second  Stage —  Comjiensation  Established. 

As  long  as  compensation  remains  perfect,  the  only  evidence  of 
regurgitation  may  be  that  obtained  by  auscultation,  and  I  shall 
accordingly  begin  with  this  rather  than  in  the  traditional  way  with 
inspection,  palpation,  and  percussion. 

The  distinguishing  auscultatory  phenomena  in  cases  of  well- 
compensated  mitral  insufficiency  are : 

(rt)  A  systolic  murmur  whose  maximum  ).' tensity  is  at  or  near 
the  apex  impulse  of  the  heart,  but  which  is  also  to  be  heard  in  the 
left  axilla  and  in  the  back  below  or  inside  the  angle  of  the  left 
scapula  (so  far  the  signs  are  those  of  the  first  stage,  above  de- 
scribed). 

{b)  A  pathological  accentuation  of  the  jjulmonic  second  sound. 

This  is  the  minimum  of  evidence  upon  which  it  is  justifiable  to 
make  the  diagnosis  of  compensated  mitral  regurgitation.  In  the 
vast  majority  of  cases,  however,  our  diagnosis  is  confirmed  by  the 
following  additional  data : 

(c)  Enlargement  of  the  heart  as  shown  by  inspection,  palpation, 
and  percussion. 

{d)  Evidence  of  congestion  of  the  lungs  (dyspnoea,  orthopnoea, 
cough,  cyanosis,  hemoptysis),  as  well  as  of  the  general  venous  sys- 
tem (engorgement  of  the  liver,  oedema  of  the  legs,  ascites,  etc.). 

The  pulse  in  well-compensated  cases  shows  no  considerable 
abnormality.  When  compensation  begins  to  fail,  or  sometimes  be- 
fore that  time,  the  most  characteristic  thing  about  the  pulse  is  its 
marked  irregularity  both  in  force  and  rhythm.  Such  irregularity 
is  at  once  more  common  and  less  serious  in  mitral  disease  than  in 
that  of  any  other  valve  ;  it  may  continue  for  years  and  be  compat- 
ible with  very  tolerable  health. 


VALVULAR  LESIONS. 


155 


Eeturning  now  to  the  details  of  the  sketch  just  given,  we  will 
take  lip  first  — 

(a)  The  Murynur. — In  children  the  murmur  of  mitral  regurgita- 
tion may  be  among  the  loudest  of  all  murmurs  to  be  heard  in  val- 


l8t 


I 


2iid 


1st 


J 


2nd. 


Fig.  88.— Diagram  to  Represent  Systolic  Mitral  Murmur.  The  heavy  lines  represent  th(  normal 
cardiac  sounds  and  the  light  lines  the  murmur,  which  in  this  case  does  not  replace  the  first 
sound  and  ''  tapers  "  off  characteristically  at  the  end. 

vular  disease,  but  this  does  not  necessarily  imply  that  the  lesion  is 
a  very  severe  one.  A  murmur  which  grows  louder  under  observa- 
tion in  a  well-compensated  valvular  lesion  may  mean  an  advance  of 
the  disease,  but  if  the  case  is  first  seen  after  compensation  has 
failed  a  faint,  variable  whiff  in  the  mitral  area  may  mean  the  se- 
verest type  of  lesion.  As  the  patient  improves  under  the  influence 
of  rest  and  cardiac  tonics,  such  a  murmur  may  grow  very  much 
louder,  or  a  murmur  previously  inaudible  may  appear. 

The  length  of  the  murmur  varies  a  great  deal  in  different  cases 
and  is  not  of  any  great  practical  importance.  It  rarely  ends 
abruptly,  but  usually  "tails  off"  at  the  end  of  systole  (see  Fig.  88). 
JLisical  murmurs  are  heard  more  often  in  mitral  regurgitation  than 
in  any  other  valve  lesion,  but  the  musical  quality  rarely  lasts 
throughoiit  the  whole  duration  of  the  murmur,  contrasting  in  this 
respect  with  musical  murmurs  produced  at  the  aortic  valve.     The 


llJU 


2iid 

I 


J_J. 


2nd 


Fig.  89.— Systolic  Mitral  Murmur  Replacing  the  First  Sound  of  the  Heart. 


first  sound  of  the  heart  may  or  may  not  be  replaced  by  the  murmur 
(see  Fig.  89).  When  the  sound  persists  and  is  heard  either  with 
or  before  the  murmur,  one  can  infer  that  the  lesion  is  relatively 
slight  in  comparison  with  cases  in  which  the  first  sound  is  wholly 


156    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

obliterated.  Fost-sijstolic  or  late  systolic  murmurs,  which  are  occa- 
sionally heard  in  mitral  regurgitation,  are  said  to  point  to  a  rela- 
tively slight  amount  of  disease  in  the  valve  (see  Fig.  90).     Kosen- 


Ist 


I 


2nd 


l8t 

1 


<>nd 


Fig.  90.— Late  Systolic  Murmur.    The  first  sound  Is  clear  and  an  Interval  intervenes  between 

it  and  the  munnur. 

bach  claims  that  the  late  systolic  murmur  is  always  due  to  organic 
disease  of  the  valves  and  never  occurs  as  a  functional  murmur. 

When  compensation  fails,  the  murmur  may  altogether  disappear 
for  a  time,  and  if  the  patient  is  then  seen  for  the  first  time  and 
dies  without  rallying  under  treatment,  it  may  be  impossible  to 


Pulmonic  second 
accented. 


Systolic  munnur 
loudest  here. 


Fro.  91.— Mitral  Regurgitation.    The  murmur  Is  heard  over  the  shaded  area  as  well  as  In  the 

back. 


make  the  diagnosis.    The  very  worst  cases,  then,  are  those  in  which, 
there  is  no  murmur  at  all. 

The  murmur  of  mitral  regurgitation  is  conducted  in  all  directions, 
but  especially  toward  the  axilla  and  to  the  back  {not  around  the 
chest,  but  directly).     In  the  latter  situation  it  is  usually  louder 


VALVULAR  LESIONS. 


157 


than  it  is  in  mid-axilla,  and  occasionally  it  is  heard  as  loudly  in  the 
back  as  anywhere  else.  This  is  no  doubt  owing  to  the  position  of 
the  left  auricle  (see  Figs.  91  and  92). 

(b)  After  compensation  is  established  and  as  long  as  it  lasts  an 
accentuation  of  the  pulmonio  second  sound  is  almost  invariably  to 
be  made  out,  and  may  be  so  marked  that  we  can  feel  and  see  it,  as 
well  as  hear  it.  Not  infrequently  one  can  also  see  and  feel  the 
pulsation  of  the  conns  arteriosus — not  the  left  auricle — in  the  second 
and  third  left  intercostal  space.      (It  may  be  well  to  mention  again 


Systolic  murmur. 


Fig.  93.— Mitral  Regurgitation.    Murmur  heard  over  the  shaded  area. 


here  that  by  accentuation  of  the  pulmonic  second  sound  one  does 
not  mean  merely  that  it  is  louder  or  sharper  in  quality  than  the 
aortic  second  sound,  smce  this  is  true  in  the  vast  majority  of  cases 
in  healthy  individuals  under  thirty  years  of  age.  Pathological  ac- 
centuation of  the  pvdmonic  second  sound  means  a  greater  intensity 
of  the  sound  than  ive  have  a  r'ujht  to  expect  at  the  age  of  the  individ- 
ual in  question.)  Occasionally  the  pulmonic  second  sound  is  redu- 
plicated, but  as  a  rule  this  pomts  to  an  accompanying  stenosis  of 
the  mitral  valve.  At  the  apex  the  second  sound  {i.e.,  the  trans- 
mitted aortic  second)  is  not  infrequently  wanting  altogether,  owing 


158     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

to  the  relatively  small  amount  of  blood  which  recoils  upon  the 
aortic  "^alves. 

(p)  Enlargement  of  the  heart,  and  more  especially  of  the  right 
ventricle,  is  generally  to  be  made  out,  and  in  the  majority  of  cases 
tnis  enlargement  is  manifested  by  disjilacement  of  the  apex  imj^ulse 
both  downward  and  toward  the  left,  but  more  especially  to  the 
left.  Percussion  confirms  the  results  of  inspection  and  palpation 
regarding  the  position  of  the  cardiac  impulse.  The  normal  sub- 
sternal dulness  is  increased  in  intensity,  and  we  can  sometimes 
demonstrate  an  enlargement  of  the  heart  toward  the  right  (see 
Fig.  91). 

In  children  (in  whom  adhesive  pericarditis  often  complicates 
the  disease)  a  systolic  thrill  may  not  infrequently  be  felt  at  the 
apex,  and  the  precordia  may  be  bulged,  and  even  in  adults  such  a 
systolic  thrill  is  not  so  rare  as  some  writers  would  have  us  sup- 
pose. 

(d)  The  puhe,  as  said  above,  shows  nothing  characteristic  at  any 
stage  of  the  disease.  AVhile  compensation  lasts,  there  is  usually 
nothing  abnormal  about  the  pulse,  although  it  may  be  somewhat 
irregular  in  force  and  rhythm,  and  may  be  weak  Avhen  compared  to 
the  i^owerful  beat  at  the  apex  in  case  the  regurgitant  stream  is  a 
very  large  one.  Irregularity  at  this  period  is  less  common  in  pure 
mitral  regurgitation  than  in  cases  complicated  by  stenosis. 

(e)  Third  Stage — Failing  Compensation. 

"When  compensation  begins  to  fail,  the  pulse  becomes  weak  and 
irregular,  and  many  heart  beats  fail  to  reach  the  wrist,  but  there, 
is  still  nothing  characteristic  about  the  pulse,  which  differs  in  no 
respect  from  that  of  any  case  of  cardiac  weakness  of  whatever 
nature. 

{e)  Evidence  of  venous  stasis,  first  in  the  lungs  and  later  in  the 
liver,  lower  extremities,  and  serous  cavities,  does  not  show  itself 
so  long  as  compensation  is  sufiicient,  but  when  the  heart  begins  to 
fail  the  patient  begins  to  complain  not  only  of  palpitation  and  car- 
diac distress,  but  of  dyspnoea,  orthopnoea,  and  cough,  and  examina- 
tion reveals  a  greater  or  lesser  degree  of  cyanosis  with  pulmo- 


VALVULAR  LESIONS.  159 

nary  oedema  manifested  by  crackling  rales  at  tlie  base  of  the  lungs 
posteriorly,  and  possibly  also  by  haemoptysis  or  by  evidences  of 
hydrothorax  (see  below,  p.  266).  If  compensation  is  not  re-estab- 
lished, the  right  ventricle  dilates,  the  tricuspid  becomes  incompe- 
tent, the  liver  becomes  enlarged  and  tender,  dropsy  becomes  gen- 
eral, the  heart  and  pulse  become  more  and  more  rapid  and  irregular, 
the  heart  murmur  disappears  and  is  replaced  by  a  confusion  of 
short  valvular  sounds,  '^ f/al/oj)  rhytluii"  or  ^^ delirium  cordis,'^  often 
considerably  obscured  by  the  noisy,  labored  breathing  with  numer- 
ous moist  rales.  In  a  patient  seen  for  the  first  time  in  such  a  con- 
dition diagnosis  may  be  impossible,  yet  mitral  disease  of  some  type 
may  usually  be  suspected,  since  murmurs  produced  at  the  aortic 
valve  are  not  so  apt  to  disappear  Avhen  compensation  fails.  The 
relative  tricuspid  insufficiency  which  often  occurs  is  likely  to  mani- 
fest itself  by  an  enlargement  of  the  right  auricle,  sometimes  demon- 
strable by  percussion  and  later  by  venous  pulsation  in  the  neck  and 
in  the  liver. 

(fZ)  Differential  Diagnosis. 

The  murmur  of  mitral  regurgitation  may  be  confused  with 

(1)  Tricuspid  regurgitation. 

(2)  Functional  murmurs. 

(3)  Stenosis  or  roughening  of  the  aortic  valves. 

(1)  The  post-mortem  records  of  the  Massachusetts  General 
Hospital  show  that  in  the  presence  of  a  murmur  due  to  mitral  re- 
gurgitation it  is  very  easy  to  fail  altogether  to  recognize  a  tricuspid 
regurgitant  murmur.  Only  5  out  of  29  cases  of  tricuspid  regurgi- 
tation found  at  autopsy  were  recognized  during  life.  AUbutt's 
figures  from  Guy's  Hospital  are  similar.  In  the  majority  of  these 
cases,  mitral  regurgitation  Avas  the  lesion  on  which  attention  was 
concentrated  during  the  patient's  life.  This  is  all  the  more  excus- 
able because  the  tricuspid  area  is  so  wide  and  uncertain.  Murmurs 
produced  at  the  tricuspid  orifice  are  sometimes  heard  with  maxi- 
mum intensity  just  inside  the  apex  impulse,  and  if  we  have  also  a 
mitral  regurgitant  murmur,  it  may  be  impossible  under  such  cir- 
cumstances to  distinguish  it  from  the  tricuspid  murmur.     Some- 


160    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

times  the  two  are  of  different  pitch,  but  more  often  tricuspid  regur- 
gitation must  be  recognized  indirecthj  if  at  all,  i.e.,  through  the 
evidence  given  by  venous  pulsation  in  the  jugular  veins  and  in  the 
liver.  Tricuspid  murmurs  are  not  transmitted  to  the  left  axilla 
and  do  not  cause  accentuation  of  the  pulmonic  second  sound,  al- 
though they  are  compatible  with  such  accentuation.  They  are  to 
be  distinguished  from  the  murmurs  of  mitral  regurgitation  by  theii- 
different  seat  of  maximum  intensity,  possibly  by  a  difference  in 
pitch,  but  most  clearly  by  the  concomitant  phenomena  of  venous 
pulsation  above  mentioned. 

(2)  "  Functional "  murmurs  are  usually  systolic  and  may  have 
their  maximum  intensity  at  the  apex  of  the  heart,  but  in  the  great 
majority  of  cases  they  are  heard  best  over  the  pulmonic  valve  or 
just  inside  or  outside  the  apex  beat  (Potain).  They  are  faint  or 
inaudible  at  the  end  of  expiration,  and  are  more  influenced  by 
position  than  organic  murmurs  are.  In  the  upright  position  they 
are  often  very  faint.  They  are  rarely  transmitted  beyond  the 
precordia  and  are  unaccompanied  by  any  evidences  of  enlargement 
of  the  heart,  by  any  pathological  accentuation  of  the  pulmonic 
second  sound,'  or  any  e\ddences  of  engorgement  of  the  lungs  or 
general  venous  system. 

(3)  Roughening  or  narrowing  of  the  aortic  valves  may  produce 
a  systolic  murmur  with  maximum  intensity  in  the  second  right  in- 
tercostal space,  but  this  murmur  is  not  infrequently  heard  all  over 
the  precordia  and  quite  plainly  at  the  apex,  so  that  it  may  simulate 
the  murmur  of  mitral  regurgitation.  The  aortic  murmur  may  in- 
deed be  heard  more  plainly  at  the  apex  than  at  any  other  point  ex- 
cept the  second  right  intercostal  space,  owing  to  the  fact  that  the 
right  ventricle,  which  occupies  most  of  the  precordial  region  be- 
tween the  aortic  and  mitral  areas,  does  not  lend  itself  well  to  the 
propagation  of  certain  types  of  cardiac  murmurs.  Under  these 
circumstances  "  a  loud,  rough  aortic  murmur  may  be  heard  at  the 

'  It  must  be  remembered  that  in  chlorosis,  a  disease  in  which  functional 
murmurs  are  especially  prone  to  occur,  the  pulmonic  second  sound  is  often 
surprisingly  loud,  owing  to  a  retraction  of  the  left  lung,  which  uncovers  the 
root  of  the  pulmonic  artery. 


VALVULAR  LESIONS.  161 

apex  as  a  smooth  murmur  of  a  different  tone  "  (Broadbeut) ,  Sucb 
a  murmur  is  not,  however,  likely  to  be  conducted  to  the  axilla  or 
heard  beneath  the  left  scapula,  nor  to  be  accompanied  by  accentua- 
tion of  the  pubnonic  second  sound  nor  evidences  of  engorgement 
of  the  lungs  and  general  venous  system. 

II,  Mitral  Stenosis. 

Narrowing  or  obstruction  of  the  mitral  orifice  is  almost  invari- 
ably the  result  of  a  chronic  endocarditis  which  gradually  glues  to- 
gether the  two  flaps  of  the  valve  until  only  a  funnel-shaped  open- 
ing or  a  slit  like  a  buttonhole  is  left  (see  Figs.  93  and  94).  As  we 
examine  post  mortem  the  tiny  slit  which  may  be  all  that  is  left  of 
the  mitral  orifice  in  a  case  of  long  standing,  it  is  difiicult  to  con- 
ceive how  sufticient  blood  to  carry  on  the  needs  of  the  circulation 
could  be  forced  through  such  an  insignificant  opening. 

Usually  a  slow  and  gradually  developed  lesion,  mitral  stenosis 
often  represents  the  later  stages  of  a  process  which  in  its  earlier 
phases  produced  pure  mitral  regurgitation.  By  some  observers  the 
advent  of  stenosis  is  regarded  as  representing  an  attempt  at  com- 
pensation for  a  reduction  of  the  previous  mitral  leakage.  Others 
consider  that  the  stenosis  simply  increases  the  damage  which  the 
valve  has  suffered. 

A  remarkable  fact  never  satisfactorily  explained  is  the  predilec- 
tion of  mitral  stenosis  for  the  female  sex.  A  large  proportion  of 
the  cases — seventy-six  per  cent  in  my  series — occur  in  women. 

It  is  also  curious  that  so  many  cases  are  associated  with  pul- 
monary tuberculosis. 

Physical  Signs. 

Mitral  stenosis  may  exist  for  many  years  without  giving  rise  to 
any  physical  signs  by  which  it  may  be  recognized,  and  even  after 
signs  have  begim  to  show  themselves  they  are  more  fleeting  and 
inconstant  than  in  any  other  valvular  lesion  of  the  heart.  In  the 
early  stages  of  the  disease  the  heart  may  appear  to  be  entirely  nor- 
mal if  the  patient  is  at  rest,  and  especially  if  examined  in  the  re- 
cumbent position,  characteristic  signs  being  elicited  only  by  exer- 
11 


162    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 


tion;  or  again  a  murmur  which  is  easily  audi! )le  with  the  patient 
in  the  upright  position  may  disaj^pear  in  the  recumbent  position ; 
or  a  murmur  may  be  heard  at  one  visit,  at  the  next  it  may  be  im- 
possible to  elicit  it  by  any  manoeuvre,  while  at  the  third  visit  it  may 


/^f/^i7/^e/t. 


7<^a/^J//tfia/. 


lU.  in. 


Fig.  93.— Diagram  to  Represent  the  Position  of  the  Valves  in  the  Normal  Heart  during  Diastole, 
the  Open  Mitral  .Allowing  the  Blood  to  Flow  Down  from  the  Left  Auricle,  the  Aortic  Closed. 

Fig.  94.— Mitral  Stenosis— Period  of  Diastole.  The  blood  flowing  from  the  left  auricle  is  ob- 
structed by  the  thickened  and  adherent  mitral  curtains. 


VALVULAR  LESIONS. 


163 


be  easily  heard  again.  These  characteristics  explain  to  a  certain 
extent  the  fact  that  differences  bi  opinion  so  often  arise  regarding 
the  diagnosis  of  mitral  stenosis,  and  that  out  of  forty-eight  cases  in 
which  this  lesion  was  found  at  autopsy  at  the  Massachusetts  General 
Hospital,  only  twenty-three  were  recognized  during  life.  !N"o  com- 
mon lesion  (with  the  exception  of  tricuspid  regurgitation)  has  been 
so  frequently  overlooked  in  our  records. 

I  shall  follow  Broadbent  in  dividing  the  symptoms  into  three 
stages,  according  to  the  extent  to  which  the  lesion  has  progressed. 


In  the  first  stage  inspection  and  palpation  show  that  the  apex 
beat  is  little  if  at  all  displaced,  and  percussion  reveals  no  increase 


Pulmonic  second 
accented. 


"  Double-shock ' 
sound. 


Presystolic  murmur 
heard  In  limited 
area. 


Fig.  95.  —Mitral  Stenosis. 


in  the  area  of  cardiac  dulness  ;  indeed,  in  rare  cases  the  heart  may 
be  smaller  than  usual.  If  one  lays  the  hand  lightly  over  the  origin 
of  the  apex  beat,  one  can  generally  feel  the  imrring  i}resystolic  thrill 
which  is  so  characteristic  of  this  disease,  more  common  indeed  than 
in  any  other.  This  thrill  is  more  marked  in  the  second  stage  of 
the  disease,  but  can  generally  be  appreciated  even  in  the  first.  It 
runs  up  to  and  ceases  abruptly  with  the  very  sharp  first  sound. 


164    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

the  sudden  shock  of  Avhich  may  be  appreciated  even  by  palpation. 
The  thrill  is  sometimes  palpable  even  when  no  murmiu"  can  be 
heard,  and  often  the  thrill  is  transmitted  to  the  axilla  when  the 
murmur  is  confined  to  the  apex  region.  On  auscultation  one 
hears,  especially  after  the  patient  has  been  exerting  himself,  and 
particularly  if  he  leans  forward  and  to  the  left,  a  short  rumble  or 
roll  immediately  preceding  the  systole  and  increasing  in  intensity 
as  it  approaches  the  first  sound  (see  Fig.  95).  At  this  stage  of 
the  disease  the  second  sound  can  still  be  heard  at  the  apex.  The 
first  sound  is  very  sharply  accented  or  snapping,  and  commimi- 
cates  a  very  decided  shock  to  the  ear  when  a  rigid  stethoscope 
is  used.  As  a  rule,  the  murmur  is  closely  confined  to  the  region 
of  the  apex  beat  and  not  transmitted  any  considerable  distance  in 
any  direction.     I  have  seen  cases  in  which  it  Avas  to  be  heard  only 

liJ  1st 

2nd 


I  ..iiiiiiiilHII 


Fig.  96.— The  Munnur  of  Mitral  Stenosis— First  Stage.  The  place  of  the  munmir  and  its  cres- 
cendo character  are  indicated  by  the  position  of  the  light  lines  just  befoi-e  the  Urst  sound 
and  by  their  Increasing  length. 

over  an  area  the  size  of  a  half-dollar.'  Very  characteristic  of  mi- 
tral stenosis  is  a  prolongation  of  the  diastolic  pause  so  that  the  inter- 
val beween  the  second  sound  of  one  cycle  and  the  first  sound  of  the 
next  is  unduly  long.  Occasionally  the  diastolic  sound  is  redupli- 
cated ("  double-shock  sound  " — Sansom)  at  this  stage  of  the  disease, 
but  this  is  much  more  frequent  in  the  later  phases  of  the  lesion." 

Irregularity  of  the  heart  beat  both  in  force  and  rhythm  is  very 
frequently  present  even  in  the  early  stages  of  the  affection.  The 
heart  may  be  regular  while  the  patient  is  at  rest,  but  slight  exer- 
tion is  often  sufficient  to  produce  marked  irregularity. 

'  It  may,  however,  be  widely  transmitted  to  the  left  axilla  and  audible  in 
the  back  or  even  over  the  whole  of  the  left  chest,  especially  when  the  stenosis 
is  combined  with  regurgitation. 

•^  This  is  the  opinion  of  most  observers.  Sansom  states  that  the  "double- 
shock  sound"  may  precede  all  other  evidences  of  mitral  stenosis. 


VALVULAR  LESIONS.  165 


II. 

In  the  second  stage  the  murmur  and  thrill  are  usually  longer  and 
may  occupy  the  whole  of  diastole,  beginning  with  considerable  in- 
tensity just  after  the  reduplicated  second  sound,  quickly  diminish- 

Ist  1st 


I Ml  I  M  M  1  inilllllll 


Fig.  97.— Type  of  Presystolic  Murmur  Often  Heard  In  the  Second  Stage  of  Mitral  Stenosis. 
•Here  the  murnuir  fills  the  whole  of  diastole,  with  a  gradual  increase  of  intensity  as  it  ap- 
proaches the  first  sound.    No  second  sound  is  audible  at  the  apex. 

ing  until  it  is  barely  audible,  and  then  again  increasing  with  a 
steady  crescendo  up  to  the  first  sound  of  the  next  cycle.'  These 
changes  may  be  graphically  represented  as  in  Figs.  97  and  98.  Dia- 
stole is  now  still  more  prolonged,  so  that  the  characteristic  rhythm 
of  this  lesion  is  even  more  marked  than  in  the  earlier  stages  of  the 
disease.  In  many  cases  at  this  stage  no  second  sound  is  to  be  heard 
at  all  at  the  apex,  although  at  the  pulmonic  orifice  it  is  loud  and 
almost  invariably  double.  (This  is  one  of  the  reasons  for  believing 
that  the  second  sound  which  we  usually  hear  at  the  apex  is  the 
transmitted  aortic  second  sound.     In  mitral  disease  the  aortic  valves 

Ist 

2nd 


2nd  I  ■  2na 

II illlilll n,,.MiillllH II 


I 


Fig.  98.— Type  of  Presystolic  Murmur  Sometimes  Heard  in  the  Second  Stage  of  Mitral  Stenosis. 
There  is  a  double  crescendo.    The  second  sound  seems  reduplicated. 

shut  feebly  owing  to  the  relatively  small  amount  of  blood  that  is 
thrown  into  the  aorta.) 

At  this  stage  of  the  disease  enlargement  of  the  heart  begins  to 
make  itself  manifest.     The  apex  unpulse  is  displaced  to  the  left — 

1  Rarely  one  finds  a  crescendo  in  the  middle  of  a  long  presystolic  roll  with 
a  diminuendo  as  it  approaches  the  first  sound. 


166     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

sometimes  as  far  as  the  mid-axillary  line,  and  often  descends  to 
the  sixth  interspace.  Occasionally  the  cardiac  dulness  is  increased 
to  the  right  of  the  sternum. 

The  instability  and  fleeting  character  of  the  murmur  in  the  ear- 
lier stages  of  the  disease  are  much  less  marked  in  this,  the  second 
stage.  The  first  sound  at  the  apex  still  retains  its  sharp,  thump- 
ing quality,  and  is  often  audible  without  the  murmur  in  the  back. 

The  irregularity  of  the  heart  is  generally  greater  at  this  stage 
than  in  the  earlier  one. 

III. 

The  third  stage  of  the  affection  is  marked  by  the  disappearance 
of  the  characteristic  murmur,  and  is  generally  synchronous  with 
the  development  of  tricuspid  regurgitation.  The  right  ventricle 
becomes  dilated  sometimes  very  markedly.  Indeed,  it  may  produce 
a  visible  pulsating  tumor  below  the  left  costal  border  and  be  mis- 
taken for  cardiac  aneurism  (Osier).  The  snapping  first  sound  and 
the  "  double-shock  "  sound  usually  remain  audible,  but  the  latter 
may  be  absent  altogether.  Diagnosis  in  this  stage  rests  largely  upon 
the  peculiar  snapping  character  of  the  first  sound,  together  with  the 
prolongation  of  diastole  and  the  very  great  irregularity  of  the  heart, 
both  in  force  and  rhythm.  At  times  a  presystolic  thrill  may  be 
felt  even  when  no  murmur  is  to  be  heard. 

The  pulse  shows  nothing  characteristic  in  many  cases  except 
that  early  and  persistent  irregularity  which  has  been  already  al- 
luded to.  In  other  cases  the  wave  is  low,  long,  easily  compressed, 
but  quite  perceptible  between  beats ;  but  for  the  lack  of  sufficient 
power  in  the  cardiac  contractions  the  pulse  would  be  one  of  high 
tension. 

As  the  disease  advances  the  irregularity  of  the  pulse  becomes 
more  and  more  marked,  and  sometimes  presents  an  amazing  contrast 
with  the  relatively  good  general  condition  of  the  circulation.  Even 
when  not  more  than  a  third  of  the  beats  reach  the  wrist,  the  patient 
may  be  able  to  attend  to  light  work  and  feel  very  well.  Such  cases 
make  us  feel  as  if  a  piilse  were  a  luxury  rather  than  a  necessity. 

Under  the  influence  of  digitalis  the  pulse  is  especially  apt  to 


VALVULAR  LESIONS.  167 

assume  the  higeminal  type  in  mitral  stenosis.  Every  other  beat  is 
then  so  abortive  that  it  fails  to  send  a  wave  to  the  wrist,  and  the 
weak  beat  is  succeeded  by  a  pause.  According  to  Broadbeut  the 
weak  beat  corresponds  to  an  abortive  contraction  of  the  left  ven- 
tricle accompanied  by  a  normal  contraction  of  the  right  ventricle, 
so  that  for  each  two  strong  beats  of  the  right  side  of  the  heart  we 
have  one  strong  and  one  weak  beat  of  the  left  side  of  the  heart. 

Mitral  stenosis  is  in  the  great  majority  of  cases  combined  with 
mitral  regurgitation,  and  it  often  happens  that  the  signs  of  regur- 
gitation are  so  much  more  prominent  than  those  of  stenosis  that 
the  latter  escape  observation  altogether,  especially  in  the  third 
stage  of  the  disease,  when  the  typical  presystolic  roll  has  disap- 
peared. In  such  cases  combined  stenosis  and  regurgitation  is  to  be 
distinguished  from  pure  regurgitation  by  the  sharpness  of  the  first 
sound,  which  would  be  very  unusual  at  this  stage  of  a  case  of  pure 
mitral  regurgitation.  The  presence  of  reduplicated  second  sound,  a 
"  double-shock  sound  "  at  the  outset  of  the  prolonged  diastolic  pause, 
and  of  great  irregularity  in  force  and  rhythm,  is  further  suggestive 
of  mitral  stenosis. 

Mitral  stenosis  is  apt  to  be  associated  with  haemoptysis,  with  en- 
gorgement of  the  liver  and  ascites,  and  especially  with  arterial  em- 
bolism. No  other  valve  lesion  is  so  frequently  found  associated 
with  embolism.  The  lungs  are  generally  very  voluminous,  and 
may  therefore  mask  an  increase  in  area  or  intensity  of  the  cardiac 
dulness. 

Differential  Diagnosis. 

I  have  already  discussed  the  difficulty  of  distinguishing  a  double 
lesion  at  the  mitral  valve  from  a  simple  mitral  regurgitation  (see 
above,  p.  161). 

Other  murmurs  which  may  be  mistaken  for  the  murmur  of  mi- 
tral stenosis  are : 

(«)  The  Austin  Flint  murmur. 

(5)  The  murmur  of  tricuspid  stenosis. 

(c)  A  rumbling  murmur  sometimes  heard  in  children,  after  an 
attack  of  pericarditis. 


168    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

(a)  The  Austin  Flint  murmur. 

In  1862  Austin  Flint  studied  two  cases  in  which  during  life  a 
typical  presystolic  roll  was  audible  at  the  apex  of  the  heart,  yet  in 
which  post  mortem  the  mitral  valve  proved  to  be  perfectly  normal, 
and  the  only  lesion  present  was  aortic  insufficiency.  This  observation 
has  since  been  verified  by  Osier,  Bramwell,  Gairdner,  and  other  com- 
petent observers.  At  the  Massachusetts  General  Hospital  we  have 
had  seven  such  cases  with  autopsy.  Yet,  despite  repeated  confir- 
mation, Flint's  observation  has  remained  for  nearly  forty  years  im- 
known  to  physicians  at  large.  Its  importance  is  this :  Given  a  case 
of  aortic  regurgitation — a  presystolic  murmur  at  the  apex  does  not 
necessarily  mean  stenosis  of  the  mitral  valve  even  though  the  mur- 
mur has  the  typical  rolling  quality  and  is  accomj^anied  by  a  jml- 
pable  thrill.  It  may  be  only  one  of  the  by-effects  of  the  aortic 
incompetency.  How  it  is  that  a  presystolic  murmur  can  be  pro- 
duced at  the  apex  in  cases  of  aortic  regurgitation  has  been  much 
debated.  Some  believe  it  is  due  to  the  impact  of  the  aortic  regur- 
gitant stream  upon  the  ventricular  side  of  the  mitral  valve,  floating 
it  out  from  the  wall  of  the  ventricle  so  as  to  bring  it  into  contact 
with  the  stream  of  blood  descending  from  the  left  auricle.  Others 
suppose  that  the  mmgling  of  the  two  currents  of  blood,  that  from 
the  mitral  and  that  from  the  aortic  orifice,  is  sufficient  to  jjroduce 
the  murmur. 

Between  the  "  Austin  Flint  murmur  "  thus  defined  and  the  mur- 
mur of  true  mitral  stenosis,  complicating  aortic  regurgitation,  diag- 
nosis may  be  impossible.  If  there  are  no  dilatation  of  the  mitral 
orifice  and  no  regurgitation,  either  from  this  cause  or  from  deformi- 
ties of  the  mitral  valve  itself,  any  evidence  of  engorgement  of  the 
pulmonary  circuit  (accentuation  of  the  pulmonic  second  sound, 
oedema  of  the  lungs,  haemoptysis,  and  cough)  speaks  in  favor  of  an 
actual  narrowing  of  the  mitral  valve,  while  the  absence  of  such 
signs  and  the  presence  of  a  predommating  hypertrophy  of  the  left 
ventricle  tend  to  convince  us  that  the  murmur  is  of  the  tyj^e  de- 
scribed by  Austin  Flint,  i.e.,  that  it  does  not  point  to  any  sten- 
osis of  the  mitral  valve.  The  sharp,  snapping  first  sound  and 
systolic  shock  so  characteristic  of  mitral  stenosis  are  said  to  be 


VALVULAR  LESIONS  169 

modified  or  absent  in  connection  with  murmurs  of  the  Austin  Flint 
tyiae. 

(b)  Tricuspid  obstruction. 

Luckily  for  us  as  diagnosticians,  stenosis  of  the  tricuspid  valve 
is  a  very  rare  lesion.  Like  mitral  stenosis  it  is  manifested  bj-  a 
l^resystolic  rolling  murmur  whose  point  of  maximum  intensity  is 
sometimes  over  the  traditional  tricuspid  area,  but  may  be  at  a  pomt 
so  near  the  mitral  area  as  to  be  easily  confused  with  stenosis  of 
the  latter  valve. 

The  difiiculty  of  distinguishing  tricuspid  stenosis  from  mitral 
stenosis  is  further  increased  by  the  fact  that  the  two  lesions  almost 
invariably  occur  in  conjunction.  Hence  we  have  two  presystolic 
murmurs,  perhaps  with  slightly  different  points  of  maximum  inten- 
sity and  i^ossibly  with  a  difference  in  quality,  but  often  quite  un- 
distinguishable  from  each  other.  In  the  vast  majority  of  cases, 
therefore,  tricuspid  stenosis  is  first  recognized  at  the  autopsy,  and 
the  diagnosis  is  at  best  a  very  difficult  one. 

(c)  Broadbent,  Rosenbach,  and  others  have  noticed  in  children 
who  have  just  passed  through  an  attack  of  pericarditis  a  rumbling 
murmur  near  the  apex  of  the  heart,  which  suggests  the  murmur  of 
mitral  stenosis.  It  is  distinguished  from  the  latter,  however,  by  the 
absence  of  any  accentuation  of  the  first  sound  at  the  apex,  as  well 
as  by  the  conditions  of  its  occurrence  and  by  its  transiency.  Such 
cases  are  important,  since  their  prognosis  is  much  more  favorable 
than  that  of  mitral  stenosis. 

Phear  (Lancet,  September  21,  1895)  investigated  46  cases  in 
which  a  presystolic  murmur  was  observed  during  life  and  no  mitral 
lesion  found  at  autopsy.  In  17  of  these  there  was  aortic  regurgi- 
tation at  autopsy ;  in  20  of  these  there  was  adherent  pericardium 
at  autopsy ;  in  9  nothing  more  than  dilatation  of  the  left  ventricle 
was  found.  In  none  of  these  cases  was  the  snapping  first  sound, 
so  common  in  mitral  stenosis,  recorded  during  life. 

It  should  be  remembered  that  patients  suffering  from  mitral 
stenosis  are  very  frequently  unaware  of  any  cardiac  trouble,  and 
seek  advice  for  angemia,  wasting,  debility,  gastric  or  pulmonary 
complaints.     This  is  less  often  true  in  other  forms  of  val\'ular  dis- 


170    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

ease.  We  should  be  especially  on  our  guard  in  cases  of  supposed 
"nervous  arrhythmia"  or  "tobacco  heart,"  if  there  has  been  an  at- 
tack of  rheumatism  or  chorea  previously.  Such  cases  may  present 
no  signs  of  disease  except  the  irregularity — yet  may  turn  out  to 
be  mitral  stenosis. 


IV.    AoKTK;     KK(JUK<iITATIOX. 

Rheumatic  endocarditis  usually  occurs  in  early  life  and  most 
often  attacks  the  mitral  valve.  The  commonest  cause  of  aortic  dis- 
ease on  the  other  hand — arterio-sclerosis — is  a  disease  of  late  mid- 


T/^fi/ia/  {f^^y»/. 


Tig.  99.— Diastole  in  Aortic  Regurgitation.    The  blood  Is  flowing  back  through  the  stumpy  and 
Incompetent  aortic  valves. 

die  life,  and  attacks  men  much  more  often  than  women.  "When 
we  think  of  aortic  regurgitation,  the  picture  that  rises  before  us  is 
usually  that  of  a  man  past  middle  life  and  most  often  from  the 
classes  who  live  by  manual  labor.  Nevertheless  cases  occur  at  all 
ages  and  in  both  sexes,  and  rheumatic  endocarditis  does  not  spare 
the  aortic  cusps  altogether  by  any  means. 

Whether  produced  by  arterio-sclerosis  extending  down  from  the 
aorta,  or  by  rhe^^matie  or  septic  endocarditis,  the  lesion  which  re- 
sults in  aortic  regurgitation  is  xxiiually  2ithichniing  and  sJiortening 
of  the  cusps  (see  Fig.  99).  In  rare  cases  an  aortic  cusp  may  be 
ruptured  as  a  result  of  violent  muscular  effort,  and  the  signs  and 


VALVULAR  LESIONS.  171 

symptoms  of  regurgitation  then  appear  suddenly.  But  as  a  rule 
the  lesion  comes  on  slowly  and  insidiously,  and  unless  discovered 
accidentally  or  in  the  course  of  routine  physical  examination  it  may 
exist  luinoticed  for  years.  Dropsy  and  cyanosis  are  relatively  late 
and  rare,  and  the  symptoms  which  first  appear  are  usually  those  of 
dyspnoea  and  precordial  distress. 

It  is  a  disputed  point  whether  relative  and  temporary  aortic 
insufficiency  due  to  stretching  of  the  aortic  orifice  ever  occurs.  If 
it  does  occur,  it  is  certainly  exceedingly  rare,  as  the  aortic  ring  is 
very  tough  and  inelastic. 

Dilatation  of  the  aortic  arch — practically  diffuse  aneurism — oc- 
curs in  almost  every  case  of  aortic  regurgitation,  and  prodiices  sev- 
eral important  physical  signs.  This  complication  is  a  very  well- 
known  one,  but  has  not,  I  think,  been  sufficiently  insisted  on  in 
text-books  of  physical  diagnosis.  It  forms  part  of  that  general 
enlargement  of  the  arterial  tree  which  is  so  characteristic  of  the 
disease. 

^Physical  Signs. 

Inspection  reveals  more  that  is  important  in  this  disease  than 
in  any  other  valvular  lesion.  In  extreme  cases  the  patient's  face 
or  hand  may  blush  visibly  with  every  systole.  Not  infrequently 
one  can  make  the  diagnosis  across  the  room  or  in  the  street  by  not- 
ing the  violent  throbbing  of  the  carotids,  Avhich  may  be  such  as  to 
shake  the  person's  whole  head  and  trunk,  and  even  the  bed  on 
which  he  lies.  No  other  lesion  is  so  apt  to  cause  a  heaving  of  the 
whole  chest  and  a  bobbing  of  the  head,  and  no  other  lesion  so  often 
causes  a  bulging  of  the  precordia,  for  in  no  other  lesion  is  the  en- 
largement of  the  heart  so  great  (cor  hovinum  or  ox-heart).  The 
throbbing  of  the  dilated  aorta  can  often  be  felt  and  sometimes  seen 
in  the  suprasternal  notch  or  in  the  second  right  interspace.  Not 
only  the  carotids  but  the  subclavians,  the  brachials  and  radials, 
the  femoral  and  anterior  tibial,  and  even  the  digital  and  dorsalis 
pedis  arteries  may  visibly  pulsate,  and  the  characteristic  jerking 
quality  of  the  pulse  may  be  seen  as  well  as  felt.  This  visible  pul- 
sation in  the  peripheral  arteries,  while  very  characteristic  of  aortic 


172    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

regurgitation,  is  occasionally  seen  in  cases  of  simple  hypertrophy  of 
the  heart  from  hard  muscular  work  (e.fj.,  in  athletes).  If  the  ar- 
teries are  extensively  calcified,  their  pulsation  become  much  less 
marked. 

The  peculiar  conditions  of  the  circulation  whereby  it  is  "  changed 
into  a  series  of  discontinuous  discharges  as  if  from  a  catapult"  (All- 
butt)  throws  a  great  tensile  strain  upon  all  the  arteries,  and  results, 
in  almost  every  long-standing  case,  in  increasing  both  their  length 


Pulsation  at  the  jugulum. 


Dulness  and  pul- 
sation  corre- 
sponding to  the 
dilated  aortic 
arch. 


Pulsating  car- 
otids. 


Diastolic  murmur. 


Displaced  cardiac 
impulse. 


Fig.  100.— Aortic  Regurgitation,  Showing  Position  of  the  Diastolic  Murmur  and  Areas  of  Visible 

Pulsation. 


and  their  diameter.  The  visible  arterial  trunks  become  tortuous 
and  distended,  while  the  arch  of  the  aorta  is  diffusely  dilated  and 
becomes  practically  an  aneurism  (see  Fig.  100).  With  each  heart 
beat  the  snaky  arteries  are  often  jerked  to  one  side  as  well  as  made 
to  throb. 

Inspection  of  the  region  of  the  cardiac  impulse  almost  always 
shows  a  very  marked  displacement  of  the  apex  beat  both  downward 
and  outward  (but  especially  the  former),  corresponding  to  the  hy- 
pertrophy of  the  left  ventricle,  which  is  usually  very  great,  and  to 


VALVULAR  LESIONS.  173 

the  downward  sagging  of  the  enlarged  aorta.  In  a  small  propor- 
tion of  the  cases  no  enlargement  of  the  heart  is  to  be  demonstrated. 
This  was  trne  of  5  out  of  the  last  G7  cases  which  I  have  notes  of, 
and  geuerally  denotes  an  early  and  slight  lesion.  Not  at  all  infre- 
quently one  finds  a  systolic  retraction  of  the  interspaces  near  the 
apex  beat  instead  of  a  systolic  Inqmlse.  This  is  probably  due  to 
the  negative  pressure  produced  within  the  chest  by  the  powerful 
contraction  of  an  hypertrophied  heart.  In  the  suprasternal  notch 
one  often  feels  as  well  as  sees  a  marked  systolic  pulsation  trans- 
mitted from  the  arch  of  the  dilated  aorta,  and  sometimes  mistaken 
for  saccular  aneurism. 

Arterial   pulsation   of   the    liver  and  spleen  are  rarely  demon- 
strable by  a  combination  of  sight  and  touch. 

Capillary  Pulsation. 

If  one  passes  the  end  of  a  pencil  or  other  hard  substance  once 
or  twice  across  the  patient's  forehead,  and  then  Avatches  the  red 
mark  so  produced,  one  can  often  see  a  systolic  flushing  of  the  hyper- 
aemic  area  with  each  beat  of  the  heart.  This  is  by  far  the  best 
method  of  eliciting  this  phenomenon.  It  may  also  be  seen  if  a  glass 
slide  is  pressed  against  the  mucous  membrane  of  the  lip  so  as  par- 
tially to  blanch  it,  or  if  one  presses  upon  the  finger-nail  so  as  par- 
tially to  drive  the  blood  from  under  it ;  but  in  both  these  manoeuvres 
error  may  result  from  inequality  in  the  pressure  made  by  the  ob- 
server upon  the  glass  slide  or  upon  the  nail.  Very  slight  movements 
of  the  observer's  fingers,  even  such  as  are  caused  by  his  own  pulse, 
may  give  rise  to  changes  simulating  capillary  pulsation.  Capillary 
pulsation  of  normal  tissues  is  not  often  seen  in  any  condition  other 
than  aortic'  regurgitation,  yet  occasionally  one  meets  with  it  in 
diseases  which  produce  very  low  tension  of  the  pulse,  such  as 
phthisis  or  typhoid,  anaemic  and  neurasthenic  conditions,  and  I 
have  twice  seen  it  in  perfectly  healthy  persons.  In  such  cases  the 
pulsation  is  usually  less  marked  than  in  aortic  regurgitation. 
Earely  pulsation  may  be  detected  in  the  peripheral  veins. 

'  Jumping  toothache  and  throbbing  felon  are  common  examples  of  capil- 
lary pulsation  in  inflamed  areas. 


174    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

Falpation. 

Palpation  verifies  the  position  of  the  cardiac  impulse  and  the 
heaving  of  the  whole  chest  wall  suggested  by  inspection.  The 
shock  of  the  heart  is  very  powerful  and  deliberate  unless  dilatation 


Fig.  101.— Sphygiuographic  Tracing  from  Normal  Pulse. 

is  extreme,  when  it  becomes  wavy  and  diffuse.  In  the  supraclavic- 
ular notch  a  systolic  thrill  is  often  to  be  felt.  A  diastolic  thrill 
in  the  precordia  is  very  rare. 

Tlie  pulse  is  important,  usually  characteristic.     The  wave  rises 


Fig.  102.— Sphygmosrraphic  Travinsr  of  thp  "  Pulsus  Celer"  in  Aortic  Regui^tatlon.    Its  col- 
lapsing character  Is  well  shown. 

very  suddenly  and  to  an  unusual  height,  then  collapses  completel;" 
and  with  great  rapidity  (pulsus  celer)  (see  Figs.  101,  102). 

This  type  of  pulse,  which  is  known  as  the  "  Corrigan  pulse  "  or 
"water-hammer  pulse,"  is  exaggerated  if  one  raises  the  patient's 
arm  above  the  head  so  as  to  make  the  force  of  gravity  aid  in  emp- 
tying the  artery.     The  quality  of  the  pulse  in  aortic  regurgitation 


VALVULAR  LESIONS.  175 

is  due  to  the  fact  that  a  large  volume  of  blood  is  suddenly  and  for- 
cibly thrown  into  the  aorta  by  the  hypertrophied  and  dilated  left 
ventricle,  thus  causing  the  characteristically  sharj)  and  sudden  rise 
in  the  peripheral  arteries.  The  arteries  then  empty  themselves  in 
two  dlvections  at  once,  forward  into  the  capillaries  and  backward 
into  the  heart  through  the  incompetent  aortic  valves;  hence  the 
sudden  collapse  in  the  pulse  which,  together  with  its  sharp  and 
sudden  rise,  are  its  important  characteristics.  The  arteries  are 
large  and  often  elongated  so  as  to  be  thrown  into  curves. 

Not  infrequently  one  can  demonstrate  that  the  radial  pulse  is 
delayed  or  follows  the  apex  impulse  after  a  longer  interval  than 
in  normal  i)ersons.  While  compensation  lasts,  the  pulse  is  usually 
regular  in  force  and  rhythm.  Irregularity  is  therefore  an  esjiecially 
grave  sign,  much  more  so  than  in  any  other  valvular  lesion. 

Percussion. 

Percussion  adds  but  little  to  the  information  obtained  by  inspec- 
tion and  paljDation,  but  verifies  the  results  of  these  methods  of  in- 
vestigation respecting  the  increased  size  of  the  heart,  and  especially 
of  the  left  ventricle,  which  may  reach  enormous  dimensions,  espe- 
cially in  cases  occurring  in  young  persons'.  The  heart  may  be 
increased  to  viore  than  four  times  its  norvial  iveight. 

Auscultation. 

In  rare  cases  there  may  be  absolutely  no  murmur  and  the  diag- 
nosis may  be  impossible  during  life,  though  it  may  be  suspected 
by  reason  of  the  above-mentioned  signs  in  the  peripheral  arteries. 
But  although  the  murmur  is  seldom  entirely  absent,  it  is  often  so 
faint  as  to  be  easily  overlooked.  This  is  especially  true  in  cases 
occurring  in  elderly  people,  and  Avhen  the  patient  has  been  for  a 
considerable  time  at  rest.  The  difficulty  of  recognizing  certain 
cases  of  aortic  regurgitation  during  life  is  shown  by  the  fact  that 
out  of  sixty-five  cases  of  aortic  regurgitation  demonstrated  at  au- 
topsy in  the  Massachusetts  General  Hospital,  only  forty-four  were 
recognized  during  life. 


176    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

In  the  majority  of  cases,  however,  the  characteristic  diastolic 
murnnw  is  easily  heard  if  one  listens  in  the  right  place,  and  when 
heard  it  is  the  most  distinctive  and  trustwovthy  of  all  cardiac  viui"- 
mui's.  It  almost  invariably  points  to  aortic  regurgitation  and  to 
nothing  else. 

The  murmur  of  aortic  regurgitation,  as  has  been  already  men- 
tioned, is  diastolic  in  time.'     Its  viaxiiuant  intensity  is  usually  not 


Fig.  103.— Position  of  the  Point  of  Maximum  Intensity  of  the  Murmur  of  Aortic  Rejnu^tation. 
The  dots  are  most  thickly  congregated  where  the  murmur  is  oftenest  heard. 


in  the  conventional  aoHie  area  (second  right  interspace),  but  on  the 
left  side  of  the  sternum  about  the  level  of  the  fourth  left  costal  carti- 
lage. In  about  one-tenth  of  the  cases,  and  especially  when  the 
aortic  arch  is  much  dilated,  the  murmur  is  best  heard  in  the  con- 
ventional aortic  area.  Occasionally  there  are  two  points  at  which 
it  may  be  loudly  heard — one  in  the  second  right  interspace  and  the 
other  at  or  near  the  apex  of  the  heart,  while  between  these  points 

'  Another  murmur,  systolic  in  time,  which  almost  always  accompanies 
the  diastolic  murmur,  is  usually  due  to  roughening  of  the  edges  of  the  aortic 
valves  or  to  dilatation  of  the  aortic  arch.  This  murmur  must  not  be  assumed 
to  mean  aortic  stenosis  (see  below,  p.  184 J. 


VALVULAR  LESIONS.  177 

the  murmur  is  faint.  This  is  probably  due  to  the  fact  that  the 
left  ventricle,  through  Avhich  the  murmur  is  conducted,  approaches 
the  surface  of  the  chest  only  at  the  apex,  while  the  intermediate  space 
is  occupied  by  the  right  ventricle,  which  often  fails  readily  to  trans- 
mit murmurs  produced  at  the  aortic  orifice.  Less  frequently  the 
mui-mur  of  aortic  regurgitation  is  heard  with  maximum  intensity 
at  the  second  or  third  left  costal  cartilage  or  in  the  region  of  the 
ensiform  cartilage  (see  Fig.  103). 

From  its  seat  of  maximmu  intensity  (i.e.,  usually  from  the 
fourth  left  costal  cartilage)  the  murmur  is  transmitted  in  all  direc- 
tions, but  not  often  beyond  the  precordia.  In  about  one-third  of 
the  cases  it  is  transmitted  to  the  left  axilla  or  even  to  the  back. 
It  is  sometimes  to  be  heard  in  the  subclavian  artery  and  the 
great  vessels  of  the  neck;   in  other   clases  two  heart   sounds   are 


Is*  Ist 

I      '  2nd  I 


2nd 


Fig.  104.— Short  Diastolic  Murmur  Not  Replacing  the  Second  Sound. 

audible  in  the  carotid,  but  no  murmur.  The  murmur  is  usually 
blowmg  and  relatively  high  pitched,  sometunes  musical.  Its  inten- 
sity varies  much,  but  is  most  marked  at  the  beginning  of  the  mur- 
mur, giving  the  impression  of  an  accent  there.  It  may  occupy  the 
Avhole  of  diastole  or  only  a  small  portion  of  it — usually  the  earlier 
portion  (see  Fig.  104).  Late  diastolic  murmurs  are  rare.  The  mur- 
mur may  or  may  not  rej)lace  the  second  sound  of  the  heart.  Broad- 
bent  believes  that  when  it  does  not  obliterate  the  second  sound, 
the  lesion  is  usually  less  severe  than  when  only  the  murmur  is  to 
be  heard.     AUbutt  dissents  from  this  opinion. 

In  listening  for  the  aortic  second  sound  with  a  view  to  gauging 
the  severity  of  the  lesion,  it  is  best  to  apply  the  stethoscope  over  the 
right  carotid  artery,  as  here  we  are  less  apt  to  be  confused  by  the 
murmur  or  by  the  pulmonic  second  sound. 

The  position  of  the  patient's  body  has  but  little  effect  upon  the 
mm'mur — less  than  upon  murmurs  produced  at  the  mitral  orifice. 
12 


178     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

The  first  sound  at  tlie  apex  is  generally  loud  and  long.  There 
is  no  accentuation  of  the  pulmonic  second. 

Over  the  larger  peripheral  arteries,  especially  over  the  femoral 
artery,  one  hears  in  most  cases  a  sharp,  short  systolic  sound  ("pis- 
tol-shot sound  ")  due  to  the  sudden  filling  of  the  unusually  empty 
artery ;  this  sound  is  merely  an  exaggeration  of  what  may  be  heard 
in  health.  Pressure  with  the  stethoscope  will  usually  bring  out  a 
systolic  murmur  (as  also  in  health),  and  occasionally  a  diastolic 
murmur  as  well  (Duroziez's  sign).  This  diastolic  murmur  in  the 
periphei-al  arteries,  obtained  on  jiressure  with  the  stethoscope,  is 
practically  never  heard  except  in  aortic  regurgitation.  It  is  thought 
by  some  to  be  due  to  the  regurgitant  current  in  the  great  vessels 
which  in  very  marked  cases  may  extend  as  far  as  the  femoral  ar- 
tery. Duroziez's  sign  is  a  comparatively  rare  one,  not  present  in 
most  cases  of  aortic  regurgitation,  and  i;sually  disappears  when 
compensation  fails. 

Summary  and  Differential  Diag7iosis. 

A  diastolic  m^wmiir  heard  with  the  maximum  intensity  about 
\:he  fouHh  left  costal  cartilarje  (less  often  in  the  second  right  inter- 
space or  at  the  apex)  gives  us  almost  complete  assurance  of  the 
existence  of  aortic  regurgitation.  From  pulmonary  regurgitation, 
an  exceedingly  rare  lesion,  the  disease  is  distinguished  by  the  pres- 
ence of  predominating  h3'pertrophy  of  the  left  ventricle  Avith  a 
heaving  apex  impulse  and  by  the  following  arterial  phenomena : 

(a)  Visible  jmlsation  in  the  peripheral  arteries. 

{h)  Capillary  pulsation. 

(c)  "Corrigan  "  pulse. 

(d)  "Pistol-shot  sound  "  in  the  femoral  artery. 

(e)  Duroziez's  sign. 

The  very  rare  functional  diastolic  murmur,  transmitted  from 
the  veins  of  the  neck  and  heard  over  the  base  of  the  heart  in  cases 
of  grave  angemia,  may  be  obliterated  by  pressure  over  the  bulbus 
jugularis.  Such  pressure  has  no  effect  upon  the  murmur  of  aortic 
regurgitation.  . 

It  must  be  remembered  that  aortic  regurgitant  murmurs  are 


VALVULAR  LESIONS.  179 

often  exceedingly  faint,  and  should  be  listened  for  with  the  greatest 
care  and  under  the  most  favorable  conditions. 

Estimation  of  the  Extent  and  Gravity  of  the  Lesion. 

The  extent  of  the  lesion  is  roughly  proportional  to — 

(a)  The  amount  of  hypertrophy  of  the  left  ventricle. 

{b)  The  degree  to  which  the  pulse  collapses  during  diastole 
(provided  the  radial  is  not  so  much  calcified  as  to  make  collapse 
imjjossible) . 

(c)  The  degree  to  which  the  murmur  replaces  the  second  sound 
as  heard  over  the  right  carotid  artery  (Broadbent). 

Irregularity  of  the  pulse  is  a  far  more  serious  sign  in  this  dis- 
ease than  in  lesions  of  the  mitral  valve,  and  indicates  the  beginning 
of  a  serious  failure  of  compensation. 

Another  grave  sign  is  a  diminution  in  the  intensity  of  the 
murmur. 

Complica  tions. 

(1)  Dilatation  of  the  Aorta. — Diffuse  dilatation  of  the  aortic  arch 
is  usually  associated  with  aortic  regurgitation  and  may  produce  a 
characteristic  area  of  dulness  to  the  right  of  the  sternum  (see  Fig. 
100).  !N"ot  infrequently  this  dilatation  is  the  cause  of  a  systolic 
murmur  to  be  heard  over  the  region  of  the  aortic  arch  and  in  the 
great  vessels  of  the  neck. 

(2)  Roughening  of  the  Aortic  Valves. — In  the  great  majority  of 
cases  of  aortic  regurgitation  the  valves  are  sufficiently  roughened 
to  produce  a  systolic  murmur  as  the  blood  flows  over  them.  This 
murmur  is  heard  at  or  near  the  conventional  aortic  area,  and  may 
be  transmitted  into  the  carotids.  (The  relation  of  these  murmurs 
to  the  diagnosis  of  aortic  stenosis  will  be  considered  with  the  latter 
lesion.) 

(3)  The  return  of  arterial  blood  through  the  aortic  valves  into 
the  left  ventricle  produces  in  time  both  hypertrophy  and  dilatation 
of  this  chamber,  and  results  ultimately  in  a  stretching  of  the  mitral 
orifice  which  renders  the  mitral  curtains  imcompetent.  The  result 
is  a  ^'i'elative  mitral  iiisufficiency,"  i.e.,  one  in  which  the  mitral  valve 


180     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

is  intact  but  too  short  to  reach  across  the  orifice  which  it  is  iu- 
tended  to  close.  Such  an  insufficiency  of  the  mitral  occurs  in  most 
well-marked  cases;  it  temporarily  relieves  the  overdistention  of  the 
left  venti-icle  and  often  the  accompanying  angina,  although  at  the 
cost  of  engorging  the  lungs.' 

(4)  The  Austin  Flint  Murmur. — The  majority  of  cases  of  aortic 
regurgitation  are  accompanied  by  a  presystolic  murmur  at  the  apex, 
which  may  be  due  to  a  genuine  mitral  stenosis  or  may  be  produced 
in  the  manner  suggested  by  Austm  Flint.  (For  a  fuller  discussion 
of  this  murmur  see  above,  p.  1G8.) 

(5)  AoHic  stenosis  frequently  supervenes  in  cases  of  aortic  re- 
gurgitation, and  results  in  a  more  or  less  temporary  improvement  in 
the  patient's  condition.  It  has  the  effect  of  increasing  the  intensity 
of  the  diastolic  murmur,  smce  the  regurgitating  stream  has  to  pass 
through  a  smaller  opening. 

The  general  visible  arterial  pulsation  becomes  much  less  marked 
if  stenosis  supervenes  on  regurgitation. 


AORTIC  STENOSIS. 

Uncomplicated  aortic  stenosis  is  by  far  the  rarest  of  the  valvu- 
lar lesions  of  the  left  side  of  the  heart,  as  well  as  the  most  difficult 
to  recognize.  Out  of  two  hundred  and  fifty-two  autojisies  made  at 
the  Massachusetts  General  Hospital  in  cases  of  valvular  disease 
there  was  not  one  of  uncomplicated  aortic  stenosis.  Twenty-nine 
cases  occurred  in  combination  with  aortic  regurgitation.  During 
life  the  diagnosis  of  aortic  stenosis  is  frequently  made,  but  often  on 
insufficient  evidence — i.e.,  upon  the  evidence  of  a  systolic  murmur 
heard  with  maximum  intensity  in  the  second  right  intercostal  space 
and  transmitted  into  the  vessels  of  the  neck.  Such  a  murmur  does 
indeed  occur  in  aortic  stenosis,  but  is  by  no  means  peculiar  to  this 
condition.  Of  the  other  diseases  which  produce  a  similar  murmur 
more  will  be  said  under  Differential  Diagnosis. 

'  This  relative  insufficiency  of  the  mitral  valve  has  been  termed  its  **  safety- 
vahe"  action,  but  the  safety  is  but  temporary  and  dearly  bought. 


VALJHJLAR  LESIONS.  181 

For  the  diagnosis  of  aortic  stenosis  we  need  the  following  evi- 
dence : 

(1)  A  systolic  murmur  heard  best  in  the  second  right  intercostal 
space  and  transmitted  to  the  neck. 

(2)  The  characteristic  pulse  (vide  infra) . 

(3)  A  palpable  thrill  (usually). 

(4)  Absence  or  great  enfeeblement  of  the  aortic  second  sound. 
Of  these  signs  the  characteristic  ^??//«e  is  probably  the  most  im- 


-^r/?t^  /yi/irjfM^^ 


^y^ia/c^j/i/. 


Fig.  105.— Aortic  Steno8ls.    The  heart  is  In  systole  and  the  blood  column  Is  obstracted  by  the 
narrowed  aortic  ring.    The  mitral  Is  closed  (as  it  should  be). 

portant,  and  no  diagnosis  of  aortic  stenosis  is  possible  without  it. 
The  heart  may  or  may  not  be  enlarged. 

Each  of  these  points  will  now  be  described  more  in  detail. 

(1)  The    Murmur. 

(a)  The  maximum  intensity  of  the  murmur,  as  has  already  been 
said,  is  usually  in  the  second  right  intercostal  space  near  the  ster- 
num or  a  little  above  that  point  near  the  sterno-clavicular  articula- 
tion, but  it  is  by  no  means  uncommon  to  find  it  lower  down,  i.e., 
in  the  third,  fourth,  or  fifth  right  interspace,  and  occasionally  it  is 
best  heard  to  the  left  of  the  sternum  in  the  second  or  third  inter- 
costal space,      (h)  The  time  of  the  murmur  is  late  systolic;  that  is, 


182     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

it  follows  the  apex  impulse  at  an  appreciable  interval,  contrasting 
in  this  respect  with  the  systolic  murmur  usually  to  be  heard  in 
mitral  regurgitation,  (c)  .The  murmur  is  usually  ividehj  transmit- 
ted, often  being  audible  over  the  whole  chest  and  occasionally  over 
the  skull  and  the  arterial  trunks  of  the  extremities  (see  Fig.  106). 
It  is  usually  heard  less  well  over  that  portion  of  the  precordia  oc- 
cupied by  the  right  ventricle,  while,  on  the  other  hand,  it  is  rela- 
tively loud  in  the  region  of  the  apex  impulse,  w^hither  it  is  trans- 
mitted through  the  left  ventricle.     The  same  line  of  transmission 


Maximum  intensity 
of    systolic    mur-  ■" 
mur  and  tbrill. 


Fig.  106.— Aortic  Stenosis.    The  murmur  is  audible  over  the  shaded  area  and  sometimes  over 

the  whole  chest. 


was  mentioned  above  as  characteristic  of  the  murmur  of  aortic  re- 
gurgitation in  many  cases.  The  murmur  is  also  to  be  heard  over 
the  carotids  and  subclavians,  and  can  often  be  traced  over  the  tho- 
racic aorta  along  the  spine  and  down  the  arms. 

Until  compensation  fails  the  murmur  is  apt  to  be  a  very  loud 
one,  especially  in  the  recumbent  position;  it  is  occasionally  au- 
dible at  some  distance  from  the  chest,  and  is  often  rough  and 
vibrating,  sometimes  musical  or  croaking.  Its  length  is  unusually 
great,  extending  throughout  the  whole  of  systole,  but  to  this  rule 
there  are  occasional  exceptions.     The  first  sound  in  the  aortic  re- 


VALVULAR  LESIONS.  183 

gioii  is  altogether  obliterated,  as  a  rule,  and  the  second  sound  is 
either  absent  or  very  feeble.' 

(2)  The  Pulse. 

Owing  to  the  opposition  encountered  by  the  left  ventricle  in 
its  attempt  to  force  blood  into  the  aorta,  its  contraction  is  apt  to 
be  prolonged ;  hence  the  pulse  wave  rises  gradually  and  late,  and  falls 
aicaij  slotrly.  This  is  shoAvn  very  well  in  sphygniographic  tracings 
(see  Fig.  107) .  But  further,  the  blood  thrown  into  the  aorta  by  the 
left  ventricle  is  prevented,  by  the  narrowing  of  the  aortic  valves, 
from  striking  upon  and  expanding  the  arteries  with  its  ordinary 
force ;  hence  the  pulse  wave  is  not  only  slow  to  rise  but  small  in 


Fig.  107.— Sphygmographic  Tracing  of  the  Pulse  in  Uncomplicated  Aortic  Stenosis.    Compare 
with  the  normal  pulse  wave  and  with  that  of  aortic  regurgitation  (page  174). 

heifjhtf  contrasting  strongly  with  the  powerful  apex  beat  (^'pulsus 
parvus").  Again,  the  delay  in  the  emptying  of  the  left  ventricle, 
brought  about  by  the  obstruction  at  the  aortic  valves,  renders  the 
contractions  of  the  heart  relatively  infrequent,  and  hence  the  pulse 
is  infrequent  {pulsus  rarus)  as  well  as  small  and  slow  to  rise.  The 
"^)?</**us  rarus,  jiarvus,  tardus"  is,  therefore,  a  most  constant  and 
important  point  in  diagnosis,  but  unfortunately  it  is  to  be  felt 
in  perfection  only  in  the  very  rare  cases  in  which  aortic  stenosis 
occurs  uncomplicated.  When  stenosis  is  combined  with  regurgita- 
tion, as  is  almost  always  the  case,  the  above-described  qualities  of 
the  pulse  are  greatly  modified  as  a  result  of  the  regurgitation.  It 
is  also  to  be  remembered  that  the  pulse  of  aortic  stenosis  is  by  no 

1  "Occasionally,  as  noted  by  W.  H.  Dickinson,  there  is  a  musical  murmur 
of  great  intensity  in  the  region  of  the  apex,  probably  due  to  a  slight  regurgita- 
tion at  high  pressure  through  the  mitral  valve."— Oslek. 


184    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

means  unalterable  and  does  not  exhibit  its  ty])ical  jDlateau  at  all 
times. 

A  less  characteristic,  but  decidedly  frequent,  variation  in  the 
pulse  wave  of  aortic  stenosis  is  the  anacrotic  curve.  The  slow, 
long  pulse  Avith  a  long  plateau  at  the  summit  is  seen  also  in  some 
cases  of  mitral  stenosis  and  renal  disease,  and  is  not  peculiar  to 
aortic  stenosis,  but  taken  in  connection  with  the  other  signs  of  the 
disease  it  has  great  value  in  diagnosis. 

(3)  T/ie  Thrill. 

In  the  majority  of  cases  an  intense  purring  vibration  may  be 
felt  if  the  hand  is  laid  over  the  upper  portion  of  the  sternum,  esjie- 
cially  over  the  second  right  intercostal  space.  This  thrill  is  con- 
tinued into  the  carotids,  can  occasionally  be  felt  at  the  ajiex,  and 
rarely  over  a  considerable  area  of  the  chest.  It  is  a  very  important 
aid  in  the  diagnosis  of  aortic  stenosis,  but  is  by  no  means  pathog- 
nomonic, since  aneurism  may  produce  a  precisely  similar  vibration 
of  the  chest  wall. 

The  heart  is  slightly  enlarged  to  the  left  and  downward  as  a 
rule,  but  the  apex  impulse  is  unusually  indistinct,  "  a  well-delined 
and  deliberate  push  of  no  great  violence  "  (Broadbent) .  Corre- 
sponding to  the  protracted  sustained  systole  the  first  sound  at  the 
apex  is  dull  and  long,  but  not  very  loud. 

Differential  Diagnosis. 

A  systolic  murmur  heard  loudest  in  the  second  right  intercostal 
space  is  by  no  means  peculiar  to  aortic  stenosis,  but  may  be  due  to 
any  of  the  following  conditions : 

(a)  Roughening,  stiffness,  fenestration,  or  slight  congenital  mal- 
formation of  the  aortic  valves. 

{h)  Roughening  or  diffuse  dilatation  of  the  arch  of  the  aorta. 

(c)  Aneurism  of  the  aorta  or  innominate  artery. 

(d)  Functional  murmurs. 

(e)  Pulmonary  stenosis. 
(/)  Open  ductus  arteriosus. 
{g)  Mitral  regurgitation. 


VALVULAR  LESIOr^S.  185 

(a  and  b)  The  great  majority  of  such  systolic  murmurs  at  the 
base  of  the  heart,  first  appearing  after  middle  life,  are  due  to  the 
causes  mentioned  above  under  o,  b,  and  c.  In  such  cases  it  is  usu- 
ally combined  with  accentuation  and  ringing  quality  of  the  aortic 
second  sound  owing  to  the  arterio -sclerosis  and  high  arterial  tension 
associated  with  the  changes  which  produce  the  murmur.  This 
accentuation  of  the  oo7'tic  second  sound  enables  us,  except  in  extraor- 
dinarily rare  cases,  to  exclude  aortic  stenosis,  in  which  the  intensity 
of  the  aortic  second  sound  is  almost  always  much  reduced. 

Diffuse  dilatation  of  the  aorta,  such  as  often  accompanies  aortic 
regurgitation,  is  a  frequent  cause  of  a  systolic  murmur  loudest  in 
the  second  right  interspace.  This  may  be  recognized  in  certain 
cases  by  the  characteristic  area  of  dulness  on  percussion  and  by  its 
association  Avith  aortic  regurgitation  of  long  standing  (see  Fig.  100) . 

Roughening  of  the  intima  of  the  aorta  (endaortitis)  is  always  to 
be  suspected  in  elderly  patients  with  calcified  and  tortuous  perii^h- 
eral  arteries,  and  such  a  condition  of  the  aorta  doubtless  favors  the 
occurrence  of  a  murmur,  especially  when  accompanied  by  a  slight 
degree  of  dilatation.  The  absence  of  a  thrill  and  a  long,  slow 
pulse  with  a  low  maximum  serves  to  distinguish  such  murmurs 
from  those  of  aortic  stenosis. 

(c)  Aneurism  of  the  ascending  arch  of  the  aorta  or  of  the  in- 
nominate artery  may  give  rise  to  every  sign  of  aortic  stenosis  except 
the  characteristic  pulse  and  the  diminution  of  the  aortic  second 
sound.  In  aneurism  we  may  have  a  well-marked  tactile  thrill  and 
a  loud  systolic  murmur  transmitted  into  the  neck,  but  there  is 
usually  some  pulsation  to  be  felt  in  the  second  right  intercostal 
space  and  often  some  difference  in  the  pulses  or  in  the  pupils,  as 
well  as  a  history  of  pain  and  symptoms  of  pressure  upon  the  tra- 
chea and  bronchi  or  recurrent  laryngeal  nerve.  In  aneurism  the 
aortic  second  sound  is  usually  loud  and  accompanied  by  a  shock, 
and  the  pulse  shows  none  of  the  characteristics  of  aortic  stenosis. 

{d)  Functional  murmurs,  sometimes  known  as  "haemic,"  are 
occasionally  best  heard  in  the  aortic  area  instead  of  in  their  usual 
situation  (second  left  intercostal  space).  They  occur  especially  in 
young,  ansemic  persons,  are  not  accompanied  by  any  cardiac  en- 


186     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

largement,  by  any  palpable  thrill,  any  diminution  in  the  aortic 
second  sound,  or  any  distinctive  abnormalities  in  the  pulse. 

(e)  Pulmonary  stenosis,  an  exceedingly  rare  lesion,  is  mani- 
fested by  a  systolic  murmur  and  by  a  thrill  whose  maximum  inten- 
sity is  usually  on  the  left  side  of  the  sternum.  In  the  rare  cases 
in  which  this  murmur  is  best  heard  in  the  aortic  area  it  may  be 
distinguished  from  the  murmur  of  aortic  stenosis  by  the  fact  that 
it  is  not  transmitted  into  the  vessels  of  the  neck,  has  no  eifect  upon 
the  aortic  second  sound,  and  is  not  accompanied  by  the  character- 
istic changes  in  the  pulse. 

(/)  The  miirmur  due  to  persistence  of  the  ductus  arteriosus 
may  last  through  systole  and  into  diastole ;  it  may  be  accompanied 
by  a  thrill,  but  does  not  affect  the  aortic  second  sound  nor  the 
pulse. 

{[/)  The  systolic  murmiir  of  aortic  stenosis  may  be  heard  loudly  at 
the  apex,  and  hence  the  lesion  may  be  mistaken  for  mitral  regur- 
gitation. But  the  maximum  intensity  of  the  murmur  of  aortic 
stenosis  is  almost  invariably  in  the  aortic  area,  and  its  association 
with  a  thrill  and  a  long,  slow  pulse  should  enable  us  easily  to  dif- 
ferentiate the  two  lesions. 

By  the  foregoing  differentiae  aortic  stenosis  may  be  distinguished 
from  the  other  conditions  which  resemble  it,  provided  it  occurs 
uncomplicated,  but  unfortunately  this  is  very  rare.  As  a  rule,  it 
occurs  in  connection  with  aortic  regurgitation,  and  its  characteristic 
signs  are  therefore  obscured  or  greatly  modified  l)y  the  signs  of  the 
latter  disease.  We  may  suspect  it  in  such  eases  (provided  the  mi- 
tral valve  is  sufficient)  when  we  have,  in  addition  to  the  signs  of 
aortic  regurgitation,  a  systolic  murmur  and  palpable  thrill  in  the 
aortic  area  transmitted  into  the  great  vessels,  a  modification  of  the 
Corrigan  pulse  in  the  direction  of  the  "pulsus  tardus,  7'arus,  par- 
vus," and  less  visible  arterial  pulsation  than  is  to  be  expected  in 
pure  aortic  regurgitation. 

Occasionally  one  can  watch  the  development  of  an  aortic  steno- 
sis out  of  what  was  formerly  a  pure  regurgitant  lesion,  the  stenosis 
gradually  modifying  the  characteristics  of  the  previous  condition. 
One  must  be  careful,  however,  to  exclude  a  relative  mitral  insuffi- 


VALVULAR  LESIONS.  187 

cieney  which,  as  has  been  already  mentioned  above,  is  very  apt  to 
supervene  in  eases  of  aortic  disease,  owing  to  dilatation  of  the  mi- 
tral orifice,  and  which  may  modify  the  characteristic  signs  of  aortic 
regiugitation  very  much  as  aortic  stenosis  does. 

TRICUSPID   REGURGITATIOX. 

Endocarditis  affecting  the  tricuspid,  valve  is  rare  in  post-foetal 
life ;  in  the  foetus  it  is  not  so  uncommon.  In  cases  of  ulcerative 
or  malignant  endocarditis  occuring  in  adult  life,  the  tricuspid  valve 
is  occasionally  involved,  but  the  majority  of  cases  of  tricuspid  dis- 
ease occur  as  a  result  of  disease  of  the  mitral  valve  and  in  the  follow- 
ing manner :  Hj-pei-trophy  of  the  right  ventricle  occurs  as  a  result 
of  the  mitral  disease,  is  followed  in  time  by  dilatation,  and  with 
this  dilatation  comes  a  stretching  of  the  ring  of  insertion  of  the 
tricuspid  valve,  and  hence  a  regurgitation  through  that  valve.  Tri- 
cuspid regurgitation,  then,  occurs  in  the  latest  stages  of  almost 
every  case  of  mitral  disease  and  sometimes  during  the  severer  at- 
tacks of  failing  compensation. 

Out  of  405  autopsies  at  Guy's  Hospital  in  which  evidence  of 
tricuspid  regurgitation  was  found,  271,  or  two-thirds,  resulted  from 
mitral  disease,  68  from  myocardial  degeneration,  55  from  pulmonary 
disease  (bronchitis,  emphysema,  cirrhosis  of  the  lung).  Very  few  of 
these  cases  had  been  diagnosed  during  life,  and  in  all  of  them  the 
valve  was  itself  healthy  but  insufficient  to  close  the  dilated  orifice. 

Gibson  and  some  other  writers  believe  that  temporary  tricuspid 
regurgitation  is  the  commonest  of  all  valve  lesions,  and  results  from 
weakening  of  the  right  ventricle  in  connection  with  states  of  anae- 
mia, gastric  atony,  fever,  and  many  other  conditions.  It  is  very 
difficult  to  prove  or  disprove  such  an  assertion. 

Tricuspid  regurgitation  is  often  referred  to  as  serving  like  the 
opening  of  a  ''  sofeft/  valve  "  to  relieve  a  temporaiy  pubnouary  en- 
gorgement. This  "safety-valve"  action,  however,  may  be  most 
disastrous  in  its  consequences  to  the  organism  as  a  whole,  despite 
the  temporaiy  relief  which  it  affords  to  the  overfilled  lungs.  The 
engorgement  is  simply  transferred  to  the  liver  and  thence  to  tha 


188     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

abdominal  organs  and  the  lower  extremities,  so  that  as  a  rule  the 
advent  of  tricuspid  regurgitation  is  recognized  not  as  a  relief  but 
as  a  serious  and  probably  fatal  disaster. 

Physical  Signs. 

(1)  A  systolic  murmur  is  heard  loudest  at  or  near  the  fifth  left 
costal  cartilage. 

(2)  Systolic  venous  pulsation  in  the  jugulars  and  in  the  liver. 

(3)  Engorgement  of  the  right  auricle  producing  an  area  of  dul- 
ness  beyond  the  right  sternal  margin. 

(4)  Intense  cyanosis. 

(1)  The  Murmur. — The  maximmn  intensity  of  the  systolic  mur- 
mui-  of  tricuspid  regurgitation  is  usually  near  the  junction  of  the  fifth 
or  sixth  left  costal  cartilages  with  the  sternum.  Leube  finds  the 
murmur  a  rib  higher  up,  but  it  is  generally  agreed  that  the  tricuspid 
area  is  a  large  one,  so  that  the  mui-miu-  may  be  heard  anjnvhere 
over  the  lower  pai-t  of  the  sternum  or  even  to  the  right  of  it.  On  the 
other  hand,  there  are  some  tricuspid  murmurs  which  are  best  heard 
at  a  point  midway  between  the  apex  impulse  and  the  ensiform  carti- 
lage. The  murmur  is  not  widely  transmitted  and  is  usually  inaudi- 
ble in  the  back ;  at  the  end  of  expiration  its  intensity  is  increased. 

In  some  cases  we  have  no  evidence  of  tricuspid  regurgitation 
other  than  the  murmur  just  described,  but — 

(2)  Of  more  importance  in  diagnosis  is  the  presence  of  a  sys- 
tolic pulsation  in  the  external  jugular  veins  and  of  the  liver,  which 
unfortunately  is  not  always  present,  but  which  when  present  is 
pathognomonic.  I  have  already  explained  (see  p.  35)  the  distinc- 
tion between  true  st/sfolic  jugular  pulsation,  which  is  pi-actically 
pathognomonic  of  tricuspid  regurgitation,  and  simple  presystolic 
undulation  or  distention  of  the  same  veins,  which  has  no  necessary 
relation  to  this  disease.  The  decisive  test  is  the  effort  permanently 
to  empty  the  vein  by  stroking  it  upward  from  below.  If  it  in- 
stantly refills  from  below  and  continues  to  pulsate,  tricuspid  regur- 
gitation is  almost  certamly  present.  If,  on  the  other  hand,  it  does 
not  refill  from  lielow,  the  cause  must  be  sought  else  where. 


VALVULAR  LESIONS.  189 

Pulsation  in  the  liver  must  be  distinguished  from  the  "jogging  " 
motion  which  may  be  transmitted  to  it  from  the  abdominal  aorta  or 
from  the  right  ventricle.  To  eliminate  these  transmitted  impulses 
one  must  be  able  to  grasp  the  liver  bimanually,  one  hand  in  front 
and  one  resting  on  the  lower  ribs  behind,  and  to  feel  it  distinctly  ex- 
pand with  every  systole,  or  else  to  take  its  edge  in  the  hand  and 
to  feel  it  enlarge  in  one's  grasp  with  every  beat  of  the  heart. 


Systolic  murmur. 


Enlarged  and  pul- 
"■     sating  liver. 


Fig.  106.— Tricuspid  Regurgitation.    The  murmur  is  heard  best  over  the  shaded  area. 

•Pressure  upon  the  liver  often  causes  increased  distention  and  pulsa- 
tion of  the  external  jugulars  if  tricuspid  regurgitation  is  present. 

(3)  Enlargement  of  the  heart,  both  to  the  right  and  to  the  left, 
as  well  as  downward,  can  usually  be  demonstrated.  In  rare  cases 
a  dilatation  of  the  right  auricle  may  be  suggested  by  a  percussion 
outline  such  as  that  shown  in  Fig.  108. 

The  pulmonic  second  sound  is  usually  not  accented.  The  im- 
portance of  this  in  differential  diagnosis  will  be  mentioned  pres- 
ently. If  a  progressive  dimmution  in  the  intensity  of  the  sound 
occurs  under  observation,  the  prognosis  is  very  grave. 

(4)  Cyanosis  is  usually  very  great,  and  dyspnoea  and  pulmonary 
oedema  often  make  the  patient's  condition  a  desperate  one. 


190     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

Differential  Diar/nosis. 

The  statistics  of  the  cases  autopsied  at  the  Massachusetts  Gen- 
eral Hospital  show  that  tricuspid  regurgitation  is  less  often  recog- 
nized during  life  than  any  other  vahiilar  lesion.  The  diagnosis 
was  made  ante  mortem  on  only  five  out  of  twenty-nine  cases. 
This  is  due  to  the  following  facts : 

(a)  Tricuspid  regurgitation  may  be  present  and  yet  give  rise  to 
no  physical  signs  which  can  be  recognized  duruig  life. 

(6)  Tricuspid  regurgitation  occurs  most  frequently  in  connec- 
tion with  mitral  regurgitation;  hence  its  signs  are  frequently 
masked  by  those  of  the  latter  lesion.  It  is,  therefore,  a  matter  of 
great  importance  as  well  as  of  great  difficulty  to  distinguish  tricus- 
pid regurgitation  from 

(1)  Mitral  Regurgitation. 

The  difficulties  are  obvious.  The  murmur  of  mitral  regurgita- 
tion has  its  maximum  intensity  not  more  than  an  inch  or  two  from 
the  point  at  which  the  tricuspid  murmur  is  best  heard.  Both  are 
systolic  in  time.     They  are,  therefore,  to  be  distinguished  only — 

(a)  In  case  we  can  demonstrate  that  there  are  two  areas  in 
which  a  systolic  murmur  is  heard  with  relatively  great  intensity, 
with  an  intervening  space  over  which  the  murmur  is  less  clearly  to 
be  heard  (see  Fig.  109). 

(Jj)  Occasionally  the  two  systolic  murmurs  are  of  different  pitch 
or  of  different  quality,  and  may  be  thus  distinguished. 

(c)  Tricuspid  murmurs  are  not  transmitted  into  the  left  axilla 
and  are  rarely  audible  in  the  back,  and  this  fact  is  of  value  in  case  we 
have  to  distinguish  between  uncomplicated  tricuspid  regurgitation 
and  uncomplicated  mitral  regurgitation.  Unfortunately  these  le- 
sions are  very  apt  to  occur  simultaneously,  so  that  in  practice  our 
efforts  are  generally  directed  toward  distinguishing  between  a  pure 
mitral  regurgitation  and  one  complicated  by  tricuspid  regurgitation. 

(d)  In  cases  of  doubt  the  phenomena  of  venous  pulsation  in  the 
jugulars  and  in  the  liver  are  decisive  if  present,  but  their  absence 
proves  nothing. 


VALVULAR  LESIONS. 


191 


(e)  Accentuation  of  the  pulmonic  second  sound  is  almost  inva- 
riably present  in  uncomplicated  mitral  disease  and  is  apt  to  disap- 
pear in  case  the  tricuspid  begins  to  leak,  since  engorgement  of  the 
lungs  is  thereby  for  the  time  relieved,  but  in  many  cases  the  pul- 
monic second  sound  remains  most  unaccountably  strong  even  when 
the  tricuspid  is  obviously  leaking. 

(2)  From  "  functional "  systolic  murmurs  tricuspid  insufficiency 
may  generally  be  distinguished  by  the  fact  that  its  murmur  is  best 


Fig.  HX).— Two  Systolic  Murmurs  (Mitral  and  Tricuspid)  with  a  "  Vanishing  Point "  between. 

heard  in  the  neighborhood  of  the  ensiform  cartilage,  and  not  in  the 
second  right  intercostal  space  where  most  functional  murmurs  have 
their  seat  of  maximum  intensity.  Functional  murmurs  are  unac- 
companied by  venous  pulsation,  cardiac  dilatation,  or  cyanosis. 

(3)  Occasionally  a  pericardial  friction  rub  simulates  the  mur- 
mur of  tricuspid  insufficiency,  but,  as  a  rule,  pericardial  friction  is 
much  more  irregular  in  the  time  of  its  occurrence  and  is  not  regu- 
larly synchronous  with  any  definite  portion  of  the  cardiac  cycle. 

Tricuspid  Stenosis. 

One  of  the  rarest  of  valve  lesions  is  narrowing  of  the  tricuspid 
valve.     No  case  has  come  under  my  observation,  and  in  1898,  Her- 


192     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

rick  was  able  to  collect  but  154  cases  from  the  world's  literature. 
Out  of  these  154  cases,  138,  or  90  per  cent,  were  combined  with 
mitral  stenosis,  and  only  12  times  has  tricusjiid  stenosis  been  known 
to  occur  alone.'  These  observations  account  for  the  fact  that  tri- 
cuspid stenosis  has  hardly  ever  been  recognized  during  life,  smce  the 
murmur  to  which  it  gives  rise  is  identical  in  time  and  quality  and 
nearly  identical  in  position  with  that  of  mitral  stenosis.  Narrow- 
ing of  the  tricuspid  valve  is  to  be  diagnosed,  therefore,  only  by  the 
recognition  of  a  presystolic  murmur  best  heard  in  the  tricuspid  area 
and  distinguished  either  by  its  pitch,  quality,  or  position  from  the 
other  presystolic  murmur  due  to  the  mitral  stenosis  which  is  almost 
certain  to  accompany  it. 

The  heart  is  usually  enlarged,  especially  in  its  transverse  direc- 
tion, but  the  enlargement  is  just  such  as  mitral  stenosis  produces, 
and  does  not  aid  our  diagnosis  at  all. 

The  diagnosis  is  still  further  complicated  in  many  cases  by  the 
presence  of  an  aortic  stenosis  m  addition  to  a  similar  lesion  at  the 
tricuspid  and  mitral  valves,  so  that  it  seems  likely  that  in  the  future 
as  in  the  past  the  lesion  will  be  discovered  first  at  autopsy. 

Pulmonary  Regurgitation. 

Organic  disease  of  the  pulmonary  valve  is  excessively  rare  in 
post-foetal  life,  but  may  occur  as  part  of  an  acute  ulcerative  or 
septic  endocarditis.  A  temporary  functional  regurgitation  through 
the  pulmonary  valve  may  be  brought  about  by  any  cause  pi'oducing 
very  high  press^ure  hi  the  pulmonary  aHery.  I  have  known  two 
medical  students  ^ath  perfectly  healthy  hearts  who  wer£  able,  by 
prolonged  holding  of  the  breath,  to  produce  a  short,  high-pitched 
diastolic  murmur  best  heard  in  the  second  and  third  left  intercostal 
spaces  and  ceasing  as  soon  as  the  breath  was  let  out.  Of  the  occur- 
rence of  a  murmur  similarly  produced  under  pathological  condi- 
tions, especially  in  mitral  stenosis,  much  has  been  Avritten  by 
Graham  Steell. 

'  Out  of  87  cases  collected  from  the  post-mortem  records  of  Guy's  Hos- 
pital, 85,  or  97  per  cent,  were  associated  with  still  more  extensive  mitral 
stenosis. 


VALVULAR  LESIONS.  193 

From  the  diastolic  inurnmr  of  aortic  regurgitation  we  may  dis- 
tinguish the  diastolic  murmur  of  pulmonary  incompetency  by  the 
fact  that  the  latter  is  best  heard  over  the  pulmonary  valve,  is  never 
transmitted  to  the  apex  of  the  heart  nor  to  the  great  vessels,  and 
is  never  associated  with  a  Corrigan  pulse  nor  with  capillary  pulsa- 
tion.' The  right  ventricle  is  hypertrophied,  the  pulmonic  second 
sound  is  sharply  accented  and  followed  immediately  by  the  murmur. 
Evidences  of  septic  embolism  of  the  lungs  are  frequently .  present 
and  assist  us  in  diagnosis.  The  regurgitation  which  may  take 
place  through  the  rigid  cone  of  congenital  pulmonary  stenosis  is 
not  recognizable  during  life. 

Pulmonary    Stenosis. 

Among  the  rare  congenital  lesions  of  the  heart  valves  this  is 
probably  the  commonest.  The  heart,  and  particularly  the  right 
ventricle,  is  much  enlarged.  There  is  a  history  of  cyanosis  and 
dyspnoea  since  birth.  A  systolic  thrill  is  usually  to  be  felt  in  the 
second  left  intercostal  space,  and  a  loud  systolic  murmur  is  heard 
in  the  same  area.     The  pulmonic  second  sound  is  weak. 

The  region  in  which  this  murmur  is  best  heard  has  been  happily 
termed  the  "  region  of  romance  "  on  account  of  the  multiplicity  of 
mysterious  murmurs  which  have  been  heard  there.  The  systolic 
murmur  of  pulmonary  stenosis  must  be  distinguished  from 

(rt)  Functional  murmurs  due  to  anaemia  and  debility  or  to  severe 
muscular  exertion,  and  possibly  associated  with  a  dilatation  of  the 
conus  arteriosus. 

(h)  Uncovering  of  the  conus  arteriosus  through  lack  of  expan- 
sion of  the  lung. 

(c)  Aortic  stenosis. 

{d)  Mitral  regurgitation. 

(e)  Aneurism. 

(/)  Roughening  of  the  intima  of  the  aortic  arch. 

'  By  registering  the  variations  of  pressure  in  tlie  traciieal  column  of  air 
Gerliardt  has  shown  gi-aphically  that  a  systolic  pulsation  of  the  pulmonary  cap- 
illaries may  occur  in  pulmonary  regurgitation.  With  the  stethoscope  a  sys- 
tolic whiff  may  be  heard  all  over  the  lungs. 

13 


194    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

(a  and  b)  Functional  murmnrs,  and  those  produced  in  the  conus 
arteriosus,  are  rarely  if  ever  accompanied  by  a  thrill,  are  rarely  so 
loud  as  the  murmur  of  pulmonary  stenosis,  and  are  not  associated 
with  dyspnoea,  cyanosis,  and  enlargement  of  the  right  ventricle. 

(c)  The  murmur  of  aortic  stenosis  is  usually  uj^on  the  right  side 
of  the  sternum  and  is  transmitted  to  the  neck,  whereas  the  murmur 
of  pulmonary  stenosis  is  never  so  transmitted  and  is  not  associated 
with  characteristic  changes  in  the  j)ulse  (see  above,  p.  183). 

(d)  The  murmur  of  mitral  regiirrjltation  is  occasionally  loudest 
in  the  region  of  the  pulmonary  valve,  but  differs  from  the  murmur 
of  pulmonary  stenosis  in  being,  as  a  rule,  transmitted  to  the  back 
and  axilla  and  associated  with  an  accentuation  of  the  pulmonary 
second  sound. 

(e)  Aneurism  may  present  a  systolic  murmur  and  thrill  similar 
to  those  found  in  pulmonary  stenosis,  but  may  usually  be  distin- 
guished from  the  latter  by  the  presence  of  the  positive  signs  of  aneur- 
ism, viz. — pulsation,  and  dulness  in  the  region  of  the  murmur,  and 
signs  of  pressure  on  the  trachea  or  on  other  structures  in  the  medi- 
astinum. 

(/)  Roughening  of  the  aortic  arch  occurs  after  middle  life, 
while  pulmonary  stenosis  is  usually  congenital.  The  murmur  due 
to  roughening  may  be  transmitted  into  the  carotids ;  that  of  pul- 
monary stenosis  never.  Enlargement  of  the  right  ventricle  is  char- 
acteristic of  pulmonary  stenosis,  but  not  of  aortic  roughening. 

COMBINED  VALVULAR   LESIONS. 

It  is  essential  that  the  student  should  understand  from  the  first 
that  the  number  of  murmurs  audible  in  the  precordia  is  no  gauge 
for  the  number  of  valve  lesions.  We  may  have  four  distinct  mur- 
murs, yet  every  valve  sound  except  one.  This  is  often  the  case  in 
aortic  regurgitation — systolic  and  diastolic  murmurs  at  the  base  of 
the  heart,  systolic  and  presystolic  at  the  apex,  yet  no  valve  in- 
jured except  the  aortic.  In  such  a  case  the  systolic  aortic  murmur 
is  due  to  roughening  of  the  aortic  valve.  The  systolic  apex  mur- 
mur results  from  relative  mitral  leakage  (with  a  sound  valve).  The 
presystolic  apex  murmur  is  of  the  "  Flint "  type.     Hence  in  this 


VALVULAR  LESIONS.  195 

ease  the  diastolic  murmur  alone  of  the  four  audible  murmurs  is  due 
to  a  valvular  lesion. 

It  is  a  good  rule  not  to  multiply  causes  minecessarily,  and  to 
explain  as  many  signs  as  possible  under  a  single  hypothesis.  In 
the  above  example  the  mitral  leak  might  be  due  to  an  old  endocar- 
ditis, and  there  mlffht  be  mitral  stenosis  and  aortic  stenosis  as  well, 
but  since  we  can  explain  all  the  signs  as  results — direct  and  indirect 
— of  one  lesion  (aortic  regurgitation)  it  is  better  to  do  so,  and  post- 
mortem experience  shows  that  our  diagnosis  is  more  likely  to  be 
right  when  it  is  made  according  to  this  principle. 

The  most  frequent  combinations  are : 

(1)  Mitral  regurgitation  with  mitral  stenosis. 

(2)  Aortic  regurgitation  with  mitral  regurgitation  (with  or  with- 
out stenosis). 

(3)  Aortic  regurgitation  with  aortic  stenosis,  with  or  without 
mitral  disease. 

(1)  Double  Mitral  Disease. 

(«)  It  very  frequently  happens  that  the  mitral  valve  is  found 
to  be  both  narrowed  and  incompetent  at  autopsy  when  only  one  of 
these  lesions  had  been  diagnosed  during  life.     In  fact  mitral  steno- 


M 


I 


Fig.  110.— Mitral  Stenosis  and  Regurgitation,  showing  relation  of  murmur  to  first  heart  sound. 

sis  is  almost  never  found  at  autopsy  without  an  associated  regurgi- 
tation, so  that  it  is  fairly  safe  to  assume,  whenever  one  makes  the 
diagnosis  of  mitral  stenosis,  that  mitral  regurgitation  is  present  as 
well,  whether  it  is  possible  to  hear  any  regurgitant  murmur  or  not 
(see  Fig.  110). 

{!))  On  the  other  hand,  Avith  a  double  mitral  lesion  one  may 
have  only  the  regurgitant  murmur  at  the  mitral  valve  and  nothing 
to  suggest  stenosis  unless  it  be  a  surprising  sharpness  of  the  first 
mitral  sound.  In  chronic  cases  the  changeableness  of  the  murmurs 
both  in  type  and  position  is  extraordinary.     One  often  finds  at  one 


196     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

visit  evidences  of  mitral  stenosis  and  at  another  evidences  of  mitral 
regurgitation  alone.  Either  murmur  may  disappear  altogether  for 
a  time  and  reappear  subsequently.  This  is  peculiarly  true  of  the  pre- 
systolic murmur,  which  is  notoriously  one  of  the  most  fleeting  and 
uncertain  of  all  physical  signs. 

As  a  rule  the  same  inflammatory  changes  which  produce  mitral 
regurgitation  in  early  life  result  as  they  extend  in  narrowing  the 
mitral  valve,  so  that  the  signs  of  stenosis  come  to  predominate  in 
later  years.  Coincidently  with  this  narrowing  of  the  diseased  valve 
a  certain  amount  of  improvement  in  the  patient's  symptoms  may 
take  place,  and  Rosenbach  regards  the  advent  of  stenosis  in  such  a 
case  as  an  attempt  at  a  regenerative  or  compensatory  change.  In 
many  cases,  however,  no  such  amelioration  of  the  symptoms  follows. 

(2)  Aortic  Regurgitation  tvith  Jlitral  Disease. 

The  signs  of  mitral  disease  occurring  in  combination  with 
aortic  regurgitation  do  not  differ  essentially  from  those  of  pure 


Systolic  murmur  /  f  jy  ^(  :^^^^^^=  )\  ^L  )  \ 
over  dilated--^-! — j~-r — w^^^^^^^SK^yn  \  \  \ 
aortic  arch.  f     /    /       ^S^:^^^^ZSJA       \\    \     Maximum  Intensity 

III        l\^~-H^  ^^^-<L-y  U        All f*"**  diastolic  mur- 

j  A\-_v_-r;^      "^^ '--+—+•       niur,    conducted 

I  I  XV~r)V/l      ^^^"oVvi   I  I       up  and  down. 

\  \KV:^(j;y*~-Oi^^^ilW -——Systolic  murmur. 


Fig.  111.— Aortic  and  Mitral  Regurgitation.    The  shaded  areas  are  those  in  which  the  murmurs 

are  loudest. 

mitral  disease  except  that  the  enlargement  of  the  heart  is  apt  to 
be  more  general  and  correspond  less  exclusively  to  the  right  ven- 
tricle (see  Figs.  Ill  and  112).     The  manifestations  of  the  aortic  le- 


VALVULAR  LESIONS.  197 

sion,  on  the  other  hand,  are  considerably  modified  by  their  associa- 
tion with  the  mitral  disease.  The  Corrigan  pulse  is  distinctly  less 
sharp  at  the  summit  and  rises  and  falls  less  abruptly.     Capillary 

iBt  1st 

■III  ^^  III  1 1  ^"^ 

illlHlMM    llimillllliiim  lillUlllllh,    III 


Fig.  112.— Showing  Relation  of  Murmurs  to  Heart  Sound  in  Regurgitation  at  the  Aortic  and 

Mitral  Valves. 

pulse  is  less  likely  to  be  present,  and  the  throbbing  of  the  peripheral 
arteries  is  less  often  visible, 

(3)  Aortic  Regurgitation  with  Aortic  Stenosis. 

If  the  aortic  valves  are  narrowed  as  well  as  incompetent,  we 
find  very  much  the  same  modification  of  the  physical  signs  charac- 
teristic of  aortic  regurgitation  as  is  produced  by  the  advent  of  a 
mitral  lesion ;  that  is  to  say,  the  throbbing  in  the  peripheral  ar- 
teries is  less  violent,  the  characteristics  of  the  radial  pulse  are  less 
marked,  and  the  capillary  j^ulsation  is  not  always  to  be  obtained 
at  all.  Indeed,  this  blunting  of  all  the  typical  manifestations  of 
aortic  regui'gitation  may  give  us  material  aid  in  the  diagnosis  of 
aortic  stenosis,  provided  always  that  the  mitral  valve  is  still  per- 
forming its  function. 

(4)  The  association  of  mitral  disease  with  tricuspid  insufficiency 
has  been  ali-eady  described  on  p.  159. 


CHAPTER  VIII. 

PAKIETAL  DISEASE.— CARDIAC  jSTEUROSES.— CONGENI- 
TAL MALFORMATIONS  OF  THE  HEART. 

Parietal  Disease  of  the  Heart. 
Acute  Myocarditis. 

The  myocardium  is  seriously,  though  not  incurably,  affected  in 
all  continued  fevers,  owing  less  to  the  fever  itself  than  to  the  tox- 
aemia associated  with  it.  " Cloudy  swelling,"  or  granular  degener- 
ation of  the  muscle  fibres,  is  produced  by  relatively  mild  infections, 
while  a  general  septicaemia  due  to  pyogenic  organisms  may  produce 
extensive /«^f^  degeneration  of  the  heart  within  a  few  days. 

The  physical  siyns  are  those  of  cardiac  tveakness.  The  most 
significant  change  is  in  the  quality  of  the  first  sound  at  the  apex 
of  the  heart,  which  becomes  gradually  shorter  and  feebler  until  its 
quality  is  like  that  of  the  second  sounds,  while  its  feebleness  makes 
the  second  sounds  seem  accented  by  comparison.  Soft  blowing 
systolic  murmurs  may  develop  at  the  pulmonary  orifice,  less  often 
at  the  apex  or  over  the  aortic  valve. 

The  apex  impulse  becomes  progressively  feebler  and  more  like 
a  tap  than  a  push.  Irreffularity  and  increasing  rajridity  are  omi- 
nous signs  which  may  be  appreciated  in  the  radial  pulse,  but  still 
better  by  auscultation  of  the  heart  itself.  In  most  of  the  acute  in- 
fections evidence  of  dilatation  of  the  weakened  cardiac  chambers  is 
rarely  to  be  obtained  during  life  (although  at  autopsy  it  is  not  in- 
frequently found),'  but  in  acute  articidar  rheumatism  an  acute  dila- 
tation of  the  heart  appears  to  be  a  frequent  complication,  independ- 

'  Henchen's  recent  monograph  on  this  subject,  "Ueber  die  acute  Herzdila- 
tation  bei  acuten  Infectionskrankheiten,"  Jena,  1899,  does  not  seem  to  me 
convincing. 


PARIETAL  DISEASE.  199 

ent  of  the  existence  of  any  valvular  disease.  Attention  has  been 
especially  called  to  this  point  by  Lees  and  Boynton  (British  Med. 
Jour.,  July  2,  1898)  and  by  S.  West. 

IxFLUEXzA  is  also  complicated  not  infrequently  by  acute  cardiac 
dilatation. 

Chronic  Mijocarditis  ("  Weakened  Heart  "J. 

Fatty  or  fibroid  changes  in  the  heart  wall  occurring  in  chronic 
disease  are  usually  the  result  of  sclerosis  of  the  coronary  arteries 
and  imperfect  nutrition  of  the  myocardium,  but  chronic  toxaemias, 
like  pernicious  aneemia,  may  also  produce  a  very  high  grade  of  fatty 
degeneration  of  the  heart  and  especially  of  the  papillary  muscles. 

Whether  fatty  or  fibroid  changes  predominate,  the  physical  signs 
are  the  same. 

Physical  Signs  of  Chronic  Myocarditis. 

For  the  recognition  of  these  changes  in  the  myocardium  our 
present  methods  of  physical  examination  are  always  unsatisfactory 
and  often  wholly  inadequate.  Extensive  degenerations  of  the 
heart -wall  are  not  infrequently  found  at  autopsy  when  there  has 
been  no  reason  to  suspect  them  during  life.  On  the  other  hand, 
the  autopsy  often  fails  to  substantiate  a  diagnosis  of  degeneration 
of  the  heart  muscle,  although  all  the  physical  signs  traditionally 
associated  with  this  condition  were  present  during  life.'  To  a  con- 
siderable extent,  therefore,  our  diagnosis  of  myocarditis  must  de- 
pend upon  the  history  and  symptoms  of  the  case ;  jihysical  exami- 
nation can  sometimes  supplement  these,  sometimes  not.  Symptoms 
of  cardiac  weakness  developing  in  a  man  jjast  middle  life,  especially 
in  a  patient  who  shows  evidences  of  arterio-sclerosis  or  high  ar- 
terial tension,  or  who  has  suffered  from  the  effects  of  alcohol  and 
syjihilis,  suggest  parietal  disease  of  the  heart,  fatty  or  fibroid. 
The  probability  is  increased  if  there  have  been  attacks  of  angina 
pectoris,  Cheyne-Stokes  breathing,  or  of  syncope. 

Inspection  and  palpation  may  reveal  nothing  abnormal,  or  there 

'  A  well-known  Boston  pathologist  recently  told  me  that  he  had  nerer 
known  a  case  of  myocarditis  correctly  diagnosed  during  life. 


200    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

may  be  an  unusually  diffuse,  slapping  cardiac  impulse  associated 
perhaps  with  a  displacement  of  the  apex  beat  to  the  left  and  dovrn- 
ward.  Marked  irregularity  of  the  heart  beat,  both  in  force  and  in 
rhythm,  is  sometimes  demonstrable  by  these  methods,  and  an  in- 
crease in  the  area  of  cardiac  dulness  may  be  demonstrable  in  ease 
dilatation  has  followed  the  weakening  of  the  heart  wall.  Ausculta- 
tion may  reveal  nothing  abnormal  except  that  the  aortic  second 
sound  is  unusually  sharp;  in  some  cases  feeble  and  irrer/ular  heart 
sounds  are  heard,  although  the  first  sound  at  the  apex  is  not  infre- 
quently sharp.  Reduplication  of  one  or  both  sounds  and  disturb- 
ance of  rhythm,  especially  the  "gallop  rhythm,"  are  not  infre- 
quent. If  the  mitral  sphincter  is  dilated,  or  the  papillary  muscles 
are  weakened,  as  not  infrequently  happens,  we  may  have  CA-idences  of 
mitral  regurgitation,  a  systolic  murmur  at  the  apex  heard  in  the  left 
axilla  and  back  with  accentuation  of  the  pulmonic  second  sound. 

Summary. 

1.  The  history  and  symptoms  of  the  case  or  the  condition  of 
other  organs  are  often  of  more  diagnostic  value  than  is  the  physical 
examination  of  the  heart  itself,  which  may  show  nothing  abnormal. 

2.  Among  the  rather  unreliable  physical  signs,  those  most  often 
mentioned  are  : 

{a)  Weakness  and  irregularity  of  the  heart  sounds. 
(J))  Accentuation  of  the  aortic  second  sound. 

(c)  A  diffuse  slapping  cardiac  impulse. 

(d)  Reduplication  of  some  of  the  cardiac  sounds  (gallop 
rhythm). 

(e)  Evidences  of  cardiac  dilatation. 

(/)  Murmurs — especially  the  murmur  of  mitral  insufficiency 
which  often  occurs  as  a  result  of  dilatation  of  the  valve  orifices  and 
weakening  of  the  cardiac  muscle. 

Differential  Diagnosis. 

We  have  to  distinguish  myocarditis  from — 
(a)  Uncomplicated  valvular  lesions. 
(J))  Cardiac  neuroses. 


PARIETAL  DISEASE.  201 

(a)  It  has  been  already  pointed  out  that  valvular  lesions  do  not 
necessarily  give  rise  to  any  murmurs  when  compensation  has  failed. 
Under  such  circumstances  one  hears  only  irregular  and  weak  heart 
sounds,  as  in  myocarditis.  The  history  of  a  long-standuig  valvu- 
lar trouble,  a  knowledge  of  the  previous  existence  of  murmurs,  the 
age,  method  of  onset,  and  symptoms  of  the  case  may  assist  us  in 
the  diagnosis.  Cases  of  myocarditis  are  less  likely  to  be  associated 
with  extensive  dropsy  than  are  cases  of  valvular  disease  whose  com- 
pensation has  been  ruptured. 

(b)  Weakness  and  irregularity  of  the  cai-diac  sounds,  when  due 
to  nervous  aifection  of  the  heart  and  unassociated  with  parietal  or 
valvular  changes,  is  usually  less  marked  after  slight  exertion.  The 
heart  "rises  to  the  occasion  "  if  the  weakness  is  a  functional  one. 
On  the  other  hand,  if  fatty  or  fibroid  changes  are  present,  the  signs 
and  symjotoms  are  much  aggravated  by  any  exertion. 

In  some  cases  of  myocarditis  the  pulse  is  excessively  slow  and 
shows  no  signs  of  weakness.  This  point  will  be  referred  to  again 
in  the  chapter  on  Bradycardia, 

Fatty  Overgroivth. 

An  abnormally  large  accumulation  of  fat  about  the  heart  may 
be  suspected  if,  in  a  very  obese  person,  signs  of  cardiac  embarrass- 
ment (dyspnoea,  palpitation)  are  present,  and  if  on  examination  we 
find  that  the  heart  sounds  are  feeble  and  distant  but  preserve  the 
normal  difference  from  each  other.  When  the  heart  wall  is  seri- 
ously weakened  (as  in  the  later  weeks  of  typhoid),  the  heart  sounds 
become  more  alike  owing  to  the  shortening  of  the  first  sound. 

In  fatty  overgrowth  this  is  not  the  case. 

The  diagnosis,  however,  cannot  be  positively  made.  We  sus- 
pect it  under  the  conditions  above  described,  but  no  greater  cer- 
tamty  can  be  attained. 

Fatty  Degeneration. 

There  are  no  physical  signs  by  which  fatty  degeneration  of  the 
heart  can  be  distinguished  from  other  pathological  changes  which 
resiilt  in  weakenmg  the  heart  walls.     An  extensive  degree  of  fatty 


202    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

degeneration  is  often  seen  post  mortem  in  cases  of  pernicious  anaemia, 
although  the  heart  sounds  have  been  clear,  regular,  and  in  all  re- 
spects normal  during  life.  The  little  we  know  of  the  physical 
signs  common  to  fatty  degeneration  and  to  other  forms  of  parietal 
disease  of  the  heart  has  been  included  m  the  section  on  Myocar- 
ditis (see  p.  198). 

Cardiac  Neuroses. 
Tachycardia  (Rapid  Heart). 

Simple  quickening  of  the  pulse  rate,  or  tachycardia,  which  may 
pass  altogether  unnoticed  by  the  patient  himself,  is  to  be  distin- 
guished from  palpitation,  in  which  the  heart  beats,  whether  rapid 
or  not,  force  themselves  upon  the  patient's  attention. 

The  pulse  rate  may  vary  a  great  deal  in  health,  A  classmate 
of  mine  at  the  Harvard  ^Medical  School  had  a  pulse  never  slower 
than  120,  yet  his  heart  and  other  organs  were  entirely  sound.  Such 
cases  are  not  very  uncommon,  especially  in  women.  Temporarily 
the  pulse  rate  may  be  greatly  increased,  not  only  by  exercise  and 
emotion,  but  by  the  influence  of  fever,  of  gastric  disturbances,  or  of 
the  menopause.  Such  a  tachycardia  is  not  always  of  brief  duration. 
The  effects  of  a  gi-eat  mental  shock  may  produce  an  acceleration  of 
the  pulse  which  persists  for  days  or  even  weeks  after  the  shock. 

Among  organic  disea.ses  associated  with  weakening  of  the  pulse 
the  commonest  are  those  of  the  heart  itself.  Next  to  them,  exoph- 
thalmic goitre,  tumors  or  hemorrhage  in  the  medulla,  and  obscure 
diseases  of  the  female  organs  of  generation,  are  the  most  frequent 
causes  of  tachycardia. 

The  only  form  of  tachycardia  which  is  worthy  to  be  considered 
as  a  more  or  less  independent  malady  is 

Paroxysmal  Tachycardia. 

As  indicated  in  the  name,  the  attacks  of  this  disease  are  apt  to 
begin  and  to  cease  suddenly.  They  may  last  a  few  hours  or  several 
days.  The  pulse  becomes  frightfully  rapid,  often  200  per  minute  or 
more.     Bristowe  records  a  case  with  a  pulse  of  308  per  minute. 


CARDIAC  NEUROSES.  203 

In  the  radial  artery  the  pulse  beat  may  be  impalpable.  The  heart 
sounds  are  regular  and  clear,  but  the  diastolic  pause  is  shortened  and 
the  first  sound  becomes  short  and  ''valvular,"  resembling  the  sec- 
ond (*^tic-tac  heart").  The  paroxysm  may  be  associated  with 
aphasia  and  abnormal  sensations  in  the  left  arm.  Occasionally  the 
heart  becomes  dilated,  and  oedema  of  the  lungs,  albuminuria,  and 
other  manifestations  of  stasis  appear.  As  a  rule,  however,  paroxys- 
mal tachycardia  can  be  distinguished  from  the  rapid  heart-beat 
associated  with  cardiac  dilatation  by  the  fact  that  the  heart  remains 
perfectly  regular.  This  same  fact  also  assists  us  in  excluding  the 
cardiac  neuroses  due  to  tobacco,  tea,  and  other  poisons.  From  the 
tachycardia  of  Graves'  disease  the  affection  now  in  consideration 
differs  by  its  paroxysmal  and  intermittent  character. 

Bradycardia  ('Slow  Heart). 

In  many  healthy  adults  the  heart  seldom  beats  over  50  times  a 
minute . 

I.  Among  the  causes  which  may  produce  for  a  short  time  an 
abnormally  slow  heart-beat  are : 

(a)  Exhaustion;  for  example,  after  fevers,  after  parturition,  or 
severe  muscular  exertion. 

(J))  Toxcemia  ;  for  example,  jaundice,  uraemia,  auto-intoxications 
in  dyspepsia. 

(c)  In  certain  hysterical  and  melancholic  states  and  in  neurotic 
children^  the  pulse  may  be  exceedingly  slow.  Pain  has  also  a  ten- 
dency to  retard  the  pulse. 

{d)  An  increase  of  intracranial  pressure,  as  in  meningitis,  cere- 
bral hemorrhage,  depressed  fracture  of  the  skull.  Possibly  in  this 
category  belong  the  cases  of  bradycardia  sometimes  seen  in  epilep- 
tiform or  during  syncopal  attacks.  Bradycardia  from  any  one  of 
these  causes  is  apt  to  be  of  comparatively  short  duration. 

II.  Permanent  bradycardia  is  most  often  associated  with  coro- 
nary sclerosis  and  myocarditi?..  In  this  disease  the  pulse  may  re- 
main below  40  for  months  or  years,  though  strong  and  regular,  yet 
the  patient  may  be  free  from  disagreeable  symptoms  of  any  kind. 
The  rate  of  the  heart-beat  cannot  always  be  estimated  by  counting 


204    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

the  radial  pulse.  Not  infrequently  many  pulsations  of  the  heart 
are  not  of  sufficient  force  to  transmit  a  wave  to  the  radial  arteiy, 
and  the  mistake  should  never  be  made  of  diagnosing  bradycardia 
simply  by  counting  the  radial  pulse. 

Ari'hi/tliinia. 

1.  Physiological  Arrhythmia. — An-hythmia,  or  irregularity  in  the 
force  or  rhythm  of  the  heart-beat,  is  to  a  certain  extent  physiologi- 
cal. The  heart  normally  beats  a  little  faster  and  a  little  more  sti-ongly 
during  inspiration  than  during  expiration.  Any  psychical  disturb- 
ance or  muscular  exertion  may  produce  irregularity  as  well  as  a 
quickening  of  the  heart -beat.  Rarely  the  pulse  may  be  irregular 
throughout  life  in  perfectly  healthy  persons.  This  irregularity  is 
usually  of  rhythm  alone ;  every  second  or  third  beat  may  be  regu- 
larly omitted  without  the  indi^ddual  knowing  anj-thing  about  it  or 
feeling  any  disagreeable  symptoms  connected  with  it.  ^More  rarely 
the  heart's  beats  may  be  permanently  irregular  in  force  as  well  as 
rhythm  despite  the  absence  of  any  discoverable  disease. 

In  children  the  pulse  is  especially  apt  to  be  ii-regular,  and  dur- 
ing sleep  some  children  show  that  modification  of  rhvthm  known 
as  the  '^jxiradoxical  j^idse,'^  which  consists  in  a  quickening  of  the 
pulse  with  diminution  in  volume  during  inspiration. 

(2)  If  we  leave  on  one  side  diseases  of  the  heart  itself,  imtho- 
logical  arrhythmia  is  most  frequently  seen  in  persons  who  have  used 
tobacco  or  tea  to  excess,  or  in  dyspepsia.  In  these  conditions  it  is 
often  combined  with  palpitation  and  becomes  therebj-  very  distress- 
ing to  the  patient.  In  connection  with  cardiac  disease  the  follow- 
ing types  of  arrhj-thmia  may  be  distinguished : 

(«)  Paradoxical  Pulse. — Any  cause  which  leads  to  weakening 
of  the  heart's  action  may  occasionally  be  associated  with  paradoxical 
pulse.  Fibrous  pericarditis  has  been  supposed  to  be  frequently 
associated  with  this  type  of  arrhj-thmia,  but  if  so  it  is  by  no  means 
its  only  cause. 

(b)  The  bigeminal  j^'ulse  is  seen  most  frequently  in  cases  of  mi- 
compensated  heart  disease  (particularly  mitral  stenosis')  after  the 
administration  of  digitalis.     Ever}'  other  beat  is  weak  or  abortive 


CARDIAC  NEUROSES.  205 

and  is  succeeded  by  an  unusually  long  pause.  Sometimes  every 
third  beat  is  of  the  abortive  type,  or  an  unusually  long  interval 
may  divide  the  heart-beats  into  groups  of  three  {'' tvireminal 
pulse  "). 

(c)  Einhryocardia,  or  the  "tic-tac  heart,"  represents  a  shorten- 
ing of  the  diastolic  pause  and  of  the  first  sound  of  the  heart  so  that 
it  resembles  the  second  sound,  as  in  the  foetal  heart.  Any  case  of 
uncompensated  heart  disease,  whether  valvular  or  paiietal,  may  be 
associated  with  this  disturbance  of  rhythm. 

(d)  The  (jdllop  rhi/thiii. 

Owing  to  a  reduplication  of  one  of  the  heart  sounds  (usually 
the  second),  we  may  have  three  sounds  instead  of  two  with  each 
beat  of  the  heart,  the  sounds  possessing  a  rhythm  which  reminds  us 
of  the  hoof -beats  of  a  galloping  horse  (see  p.  123).  This  rhythm  is 
heard  especially  in  the  failing  heart  of  interstitial  nephritis  or  cor- 
onary sclerosis. 

(e)  Delirium  cordis  is  a  term  used  to  express  any  great  irregu- 
larity and  rapidity  of  the  heart-ljeats  which  cannot  be  reduced  to 
a  single  type  or  rhythm.  It  is  seen  in  the  gravest  stages  of  uncom- 
pensated heart  disease. 

Palpitation. 

Defined  by  Osier  as  "irregular  or  forcible  heart  action  percep- 
tible to  the  individual."  The  essential  point  is  that  the  individual 
becomes  conscious  of  each  beat  of  his  heart,  whether  or  no  the  heart 
action  is  in  any  way  abnormal. 

(«)  In  irritable  conditions  of  the  nervous  system,  such  as  occur 
at  puberty,  at  climacteric,  or  in  neurasthenic  persons,  palpitation 
may  be  very  distressing.  Tempoi-ary  disturbances,  such  as  fright, 
may  produce  a  similar  and  more  or  less  lasting  effect. 

(b)  The  effect  of  high  altitudes,  or  of  even  a  moderate  eleva- 
tion (1,500  feet)  is  sufiicient  to  produce  in  many  healthy  persons  a 
quickening  and  strengthening  of  the  heart's  action,  so  that  sleep 
may  be  prevented.  After  a  few  nights  this  condition  usually 
passes  off,  provided  the  heart  is  sound, 

(c)  Abuse  of  tobacco  and  tea  have  a  similar  effect. 


206    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

Auscultation  of  a  palpitating  heart  shows  nothing  more  than 
unusually  loud  and  ringing  heart  sounds,  but  since  palpitation  is 
often  associated  with  arrhythmia  of  one  or  another  type  Ave  must  be 
careful  to  exclude  the  j^alpitation  symptomatic  of  acute  dilatation 
of  the  heart,  such  as  may  occur  in  debilitated  persons  after  violent 
or  unusual  exertion.  In  this  condition  the  area  of  cardiac  dulness 
is  increased  and  dyspnoea  upon  slight  exertion  becomes  marked.  It 
goes  without  saying  that  in  almost  any  case  of  oi'ganic  disease  of 
the  heart  palpitation  may  be  a  very  marked  and  distressing  symp- 
tom. 

CONGENITAL  HEAET  DISEASE. 

From  the  time  of  birth  it  is  noticed  that  the  child  is  markedly 
and  permanently  cyanosed,  hence  the  term  "  blue  baby. "  Dyspnoea 
is  often,  though  not  always,  present,  and  may  interfere  with  suck- 
ing. The  cyanosis  is  practically  sufficient  in  itself  for  the  diag- 
nosis. 

Among  congenital  diseases  of  the  heart  the  commonest  and  the 
most  important  (because  it  is  less  likely  than  any  of  the  others  to 
prove  immediately  fatal)  is : 

1.  Pulmonary  Stenosis. 

This  lesion  is  usually  the  result  of  foetal  endocarditis,  and  is 
often  associated  with  malformations  and  defects,  such  as  patency 
of  the  foramen  ovale  and  persistence  of  the  ductus  arteriosus.  The 
physical  signs  of  pulmonary  stenosis  are : 

(a)  A  palpable  systolic  thrill  most  distinct  in  the  pulmonary 
area. 

(b)  A  loud  murmur  (often  rough  or  musical)  heard  best  in  the 
same  region,  but  usually  transmitted  to  all  parts  of  the  chest. 

(c)  A  weak  or  absent  pulmonic  second  sound. 

{(1)  An  increased  area  of  cardiac  dulness  corresponding  to  the 
right  ventricle. 

Unlike  most  other  varieties  of  congenital  heart  disease,  pulmo- 
nary stenosis  is  compatible  with  life  for  many  years,  and  "blue 
babies  "  with  this  lesion  may  grow  up  and  enjoy  good  health,  al- 


CONGENITAL  HEART  DISEASE.  207 

thougli  usually  subject  to  pulmouaiy  disorders  (pneumonia  or  tu- 
berculosis) For  a  discussion  of  the  differential  diagnosis  of  this 
lesion,  see  above,  ji.  193. 

2.  Defects  in  the  Ventricular  Septum. 

The  loud  systolic  murmur  produced  by  the  rush  of  blood  through 
an  opening  between  the  ventricles  is  heard,  as  a  rule,  over  the  whole 
precordia.  Its  point  of  maximum  intensity  differs  in  different 
cases,  but  is  hardly  ever  near  the  apex  of  the  heart.  The  most  im- 
portant diagnostic  point  is  the  absence  of  a  palpable  thrill.  With 
almost  every  other  form  of  congenital  heart  disease  in  which  a  loud 
murmur  is  audible,  there  is  a  thrill  as  well  Hypertrophy  of  both 
ventricles  may  be  present,  but  is  seldom  marked  in  uncomplicated 
cases. 

(^Patency  of  the  foramen  ovale,  if  unassociated  with  other  de- 
fects, does  not  usually  produce  any  murmur  or  other  signs  by  which 
it  can  be  recognized  during  life,  and  causes  no  symptoms  of  any 
kind.) 

3.  Persistence  of  the  Ductus  Arteriosus. 

The  most  characteristic  sign  is  a  loud,  vibratory  systolic  mur- 
mur with  its  intensity  at  the  base  of  the  heart  and  u7iassociated  icith 
hypertrophy  of  either  ventricle.  If  complicated  with  stenosis  at  or 
close  above  the  pubuonary  valves,  persistence  of  the  ductus  arte- 
riosus cannot  be  diagnosed,  as  the  murmur  produced  by  it  cannot 
with  certainty  be  distinguished  from  that  of  the  pulmonary  ste- 
nosis, and  the  presence  of  hyjjertrophy  of  the  right  ventricle  de- 
prives us  of  the  one  relatively  characteristic  mark  of  a  patent  arte- 
rial duct. 

It  has  been  claimed  that  a  murmur  persisting  through  systole 
and  into  diastole  is  diagnostic  of  an  open  arterial  duct,  but  this 
supposition  is  not  borne  out  by  post-mortem  evidence. 

The  signs  produced  by  the  other  varieties  of  congenital  heart 
disease,  such  as  aortic  stenosis  and  tricuspid  or  mitral  lesions,  do 
not  differ  materially  from   those  characterizing  those   lesions   in 


208    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

adults.     Excluding  these,  we  may  summarize  the  signs  of  the  other 
lesions  as  follows : 

(ii)  Practically  all  cases  of  congenital  heart  disease,  which  pro- 
duce any  physical  signs  beyond  cyanosis  and  dyspnoea,  manifest 
themselves  by  a  loud  systolic  murmur  heard  all  over  the  precordia 
and  often  throughout  the  chest.  Its  maximum  intensity  is  usually 
at  or  near  the  base  of  the  heart. 

(b)  If  there  is  no  thrill  and  no  hijjiertrophy,  the  lesion  is  prob- 
ably a  defect  in  the  ventricular  septum. 

(c)  If  there  is  a  thrill  hut  no  hypertrophy,  the  lesion  is  probably 
a  patent  ductus  arteriosus. 

(c?)  If  there  is  a  thrill  and  hypertrophy  of  the  right  ventricle, 
the  lesion  is  probably  pulmonic  stenosis,  especially  if  the  pulmonic 
second  sound  is  feeble. 


CHAPTER  IX. 

DISEASES  OF  THE  PERICARDIUM. 

I.  Pekicarditis. 

Three  forms  are  recognized  clinically : 

(1)  Plastic,  dry,  or  fibrinous  pericarditis. 

(2)  Pericarditis  with  effusion  (serous  or  purulent), 

(3)  Pericardial  adhesions  or  adherent  pericardium. 
Fibrinous  pericarditis  may  be  fully  developed  without  giving 

rise  to  any  physical  signs  that  can  be  appreciated  during  life.  In 
several  cases  of  pneumonia  in  which  I  suspected  that  pericarditis 
might  be  present,  I  have  listened  most  carefully  for  evidences  of 
the  disease  and  been  unable  to  discover  any ;  yet  at  autopsy  it  was 
found  fully  developed — the  typical  shaggy  heart.  We  have  every 
reason  to  believe,  therefore,  that  pericarditis  is  frequently  present 
but  unrecognized,  especially  in  pneumonia  and  in  the  rheumatic  at- 
tacks of  children.  On  the  other  hand,  it  may  give  rise  to  very 
marked  signs  which  are  the  result  of — 

(a)  The  rubbing  of  the  roughened  pericardial  surfaces  against 
one  another  when  set  in  motion  by  the  cardiac  contractions. 

(b)  The  presence  of  fluid  in  the  pericardial  sac. 

(c)  The  interference  with  cardiac  contractions  brought  about  by 
obliteration  of  the  pericardial  sac  together  with  the  results  of  ad- 
hesions between  the  pericardium  and  the  surrounding  structures. 

(1)  Dry  or  Fibrinous  Pericarditis. 

The  diagnosis  rests  upon  a  single  physical  sign — " jjet'icardial 

friction  " — which  is  usually  to  be  appreciated  by  auscultation  alone, 

but  may  occasionally  be  felt  as  Avell.     Characteristic  pericardial 

friction  is  a  rough,  irregular,  grating  or  shuffling  sound  which  oc- 

14 


210    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

curs  irregularly  and  interruptedly  during  the  larger  part  of  each, 
cardiac  cycle.  It  is  almost  never  accurately  synchronous  either 
with  systole  or  diastole,  but  ocerlajjs  the  cardiac  sounds,  and  en- 
croaches upon  the  pauses  in  the  heart  cycle.  It  is  seldom  exactly 
the  same  in  any  two  successive  cardiac  cycles  and  differs  thereby 
from  sounds  produced  within  the  heart  itself.  Pericardial  friction 
seems  very  near  to  the  ear  and  may  often  be  increased  by  pressure 


Perioardial  friction. 


Fig.  113.— Showing  Most  Frequent  Site  of  Audible  Pericardial  Friction. 


with  the  stethoscope ;  it  is  not  materially  influenced  by  ihe  respi- 
ratory movements. 

It  is  best  heard  in  the  majority  of  cases  in  the  position  shown 
in  Fig.  113 ;  that  is,  over  that  portion  of  the  heart  which  lies  near- 
est to  the  chest  wall  and  is  not  covered  by  the  marguis  of  the  lungs ; 
but  not  infrequently  it  may  be  heard  at  the  base  of  the  heart  or 
over  the  whole  precordial  region.  The  sounds  are  fainter  if  the 
patient  lies  on  the  right  side,  and  sometimes  intensified  if,  while 
sitting  or  standing,  he  leans  forward  and  toward  the  left,  so  as  to 
bring  the  heart  into  closer  apposition  Avith  the  chest  wall. 

Pericardial  friction  sounds  often  change  rapidly  from  hour 
to  hour,  and  may  disappear  and  reappear  in  the  course  of  a 
day. 


DISEASES  OF  THE  PERICARDIUM.  211 

In  rare  cases  the  friction  may  occur  only  during  systole  or  only 
during  diastole.  In  such  cases  tlie  diagnosis  between  pericardial 
and  intracardial  sounds  may  be  very  difficult. 

Differential  Diagnosis. 

(a)  Phiiro-Pericardial  Friction. 

Fibrinous  inflammation  affecting  that  j^art  of  the  pleura  which 
overlaps  the  heart  may  give  rise  to  sounds  altogether  indistinguisli- 
able  from  those  of  true  pericardial  friction  when  the  inflamed  pleu- 
ral surfaces  are  made  to  grate  against  one  another  by  the  move- 
ments of  the  heart.  Such  sounds  are  sometimes  increased  in 
intensity  during  forced  respiration  and  disappear  at  the  end  of 
expiration,  while  true  pericardial  friction  is  usually  best  heard  if 
the  breath  is  held  at  the  end  of  expiration.  If  a  friction  sound 
heard  in  the  pericardial  region  ceases  altogether  when  the  breath 
is  held,  we  may  be  sure  that  it  is  produced  in  the  pleura  and  not 
in  the  pericardium,  but  in  many  cases  the  diagnosis  cannot  be  made 
correctly. 

{!/)  Intracardiac  Murmurs. 

From  murmurs  due  to  vahailar  disease  of  the  heart,  pericardial 
friction  can  usually  be  distinguished  by  the  fact  that  the  sounds  to 
which  it  gives  rise  do  not  accurately  correspond  either  with  systole 
or  diastole,  and  do  not  occupy  constantly  any  one  portion  of  either 
of  these  periods.  Cardiac  murmurs  are  more  regular,  seem  less 
superficial,  and  vary  less  with  position  and  from  hour  to  hour. 
Pressure  with  the  stethoscope  does  not  increase  so  considerably  the 
intensity  of  intracardiac  murmurs.  When  endocarditis  and  peri- 
carditis occur  simultaneously,  it  may  be  very  difficult  to  distinguish 
the  two  sets  of  sounds  thus  produced.  The  pericardial  friction  is 
usually  recognized  with  comparatively  little  difficulty,  but  it  is 
hard  to  make  sure  whether  in  addition  we  hear  endocardial  mur- 
murs as  Avell. 


212    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

(2)  Pericardial  Effusiox. 

Following  the  fibrinous  exudation,  which  roughens  the  pericar- 
dial surface  and  produces  the  friction  sounds  just  described,  serum 
may  accumulate  in  the  pericardial  sac.  Its  quantity  may  exceed 
but  slightly  the  amount  of  fluid  normally  present  in  the  pericar- 
dium, or  may  be  so  great  as  to  embarrass  the  cardiac  movements 
and  finally  to  arrest  them  altogether.  In  chronic  (usually  tubercu- 
lous) cases,  the  pericardium  may  become  stretched  so  as  to  hold  a 
quart  or  more  without  seriously  interfering  with  the  heart's  action, 
while  a  much  smaller  quantity,  if  effused  so  rapidly  that  the  peri- 
cardium has  no  time  to  accommodate  itself  by  stretching,  will  prove 
rapidly  fatal. 

Hydropericardium  denotes  a  dropsy  of  the  pericardium  occur- 
ring by  transudation  as  part  of  a  general  dropsy  in  cases  of  renal 
disease  or  cardial  weakness.  The  physical  signs  to  which  it  gives 
rise  do  not  differ  from  those  of  an  inflammatory  effusion,  and,  ac- 
cordingly, all  that  is  said  of  the  latter  in  the  following  section  may 
be  taken  as  equally  an  account  of  the  signs  of  hydropericardium. 

Hsemopericardium,  or  blood  in  the  pericardial  sac,  due  to  stabs 
or  to  ruptures  of  the  heart,  is  usually  so  rapidly  fatal  that  no 
physical  signs  are  recognizable. 

Physical  Signs  of  Pericardial  Effusion. 

In  most  cases  a  pericardial  friction  rub  has  been  observed  prior 
to  the  time  of  the  fluid  accumulation.  The  presence  of  fluid  in  the 
pericardial  sac  is  shown  chiefly  in  three  ways : 

(1)  By  percxission,  Avhich  demonstrates  an  area  of  dubiess  more 
or  less  characteristic  (see  below). 

(2)  By  auscultation,  which  may  reveal  an  unexpected  feebleness 
in  the  heart  sounds  when  compared  with  the  power  shown  in  the 
radial  pulse. 

(3)  By  the  signs  and  symptoms  of  j^ressure  exerted  by  the  peri- 
cardial effusion  upon  surrounding  structures. 

Bulging  of  the  precordia  is  occasionally  to  be  seen  in  chilcben ; 


DISEASES  OF  THE  PERICARDIUM. 


213 


in  adults  we  sometimes  observe  a  flattening  of  the  interspaces  just 
to  the  right  of  the  sternum  between  the  third  and  sixth  ribs. 

(1)  27te  Area  of  Percussion  Dulness. — (o)  One  of  the  most  char- 
acteristic points  is  the  unusual '  extension  of  the  percussion  dulness 
a  considerable  distance  to  the  left  and  beyond  the  cardiac  impulse. 
(Ji)  Next  to  this,  it  is  important  to  notice  a  change  in  the  angle 
made  by  the  junction  of  the  horizontal  line  corresponding  to  the 
upper  limit  of  hepatic  dulness  and  the  nearly  perpendicular  line 
corresponding  to  the  right  border  of  the  heart.     In  health  this 


Tympany, 


1 Dulness, 


Cardiac  impulse. 


Liver  dulness. 


Fig.  114.— Percussion  Dulness  in  Pericardial  Effusion,  with  Tympanitic  Resonance  Under  the 

Left  Clavicle. 

cardio-hepatic  angle  is  approximately  a  right  angle ;  in  pericardial 
effusion  it  is  much  more  obtuse  (see  Fig.  114).  Rotch  has  called 
attention  to  the  importance  of  dulness  in  the  fifth  right  intercostal 
space  as  a  sign  of  pericardial  effusion,  but  a  similar  dulness  may  be 
produced  by  enlargement  of  the  liver. 

Except  for  the  two  points  mentioned  above  (the  unusual  extension 
of  the  dulness  to  the  left  of  the  cardiac  impulse  and  the  blunting  of 
the  cardio-hepatic  angle),  there  seems  to  me  to  be  nothing  charac- 
teristic about  the  area  of  dulness  produced  by  pericardial  friction. 

1  In  health  the  cardiac  duhiess  extends  about  three-fourths  of  an  inch  be- 
yond the  cardiac  impulse,  but  in  pericardial  effusion  the  difference  is  gi-eater. 


214     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

The  "  pear-shaped  "  or  triangular  area  of  percussion  dulness  men- 
tioned by  many  Avriters  has  not  been  present  in  cases  which  have 
come  under  my  observation.  In  large  effusions  percussion  reso- 
nance may  be  diminished  in  the  left  back,  and  under  the  left  clav- 
icle the  percussion  note  may  be  tympanitic  from  relaxation  of  the 
lung.  Traube's  semilunar  space  may  be  obliterated,  but  this  occurs 
also  in  pleuritic  effusions. 

In  some  cases  the  area  of  dulness  may  be  modified  by  change  in 
the  patient's  position.  After  marking  out  the  area  of  percussion 
dulness  with  the  patient  in  the  upright  position,  let  hiin  lie  upon 
his  right  side.  The  right  border  of  the  area  of  dulness  Avill  some- 
times move  considerably  farther  to  the  right.  A  dilated  heart  can 
be  made  to  shift  in  a  similar  way,  but  to  a  lesser  extent.  Compar- 
atively little  change  takes  place  if  the  patient  lies  on  his  left  side, 
and  no  important  information  is  elicited  by  placing  him  fiat  on  his 
back  or  by  getting  him  to  lean  forward. 

Unfortunately,  it  is  only  Avith  moderate-sized  effusions  occur- 
ring in  a  pericardial  sac  free  from  adhesions  to  the  surrounding 
parts  that  this  shifting  can  be  made  out.  Large  effusions  may  not 
shift  appreciably,  and  less  than  150  c.c.  of  fluid  probably  cannot  he 
recognized  by  this  or  by  any  other  method.  But  with  large  effu- 
sions the  lateral  extension  of  the  area  of  dulness  may  be  so  great 
as  to  be  almost  distinctive  in  itself,  i.e.,  from  the  middle  of  the  left 
axilla  nearly  to  the  right  nipple. 

(2)  The  feebleness  of  the  heart  sounds,  especially  those  at  the 
apex,  is  of  diagnostic  importance  only  in  the  rare  cases  when  it  oc- 
curs in  connection  with  a  relatively  normal  condition  of  the  radial 
pulse.  In  most  diseases  feeble  heart  sounds  are  associated  with  a 
weak  pulse,  but  occasionally  in  pericardial  effusion  the  pulse  may 
be  of  good  quality,  although  the  heart  sounds  are  heard  with  diffi- 
culty. 

Broncho-vesicular  breathing  with  increased  voice  sounds  may 
be  heard  over  the  tympanitic  area  below  the  left  clavicle  and  occa- 
sionally between  the  scapula  behind.  This  is  a  result  of  compres- 
sion of  the  lung. 

(3)  Pressure  exerted  by  the  pericardial  exudation  upon  sur- 


DISEASES  OF  THE  PERICARDIUM.  215 

rounding  structures  may  give  rise  to  dyspna?a,  especially  of  a 
paroxysmal  type,  to  dysphagia,  to  aphonia,  and  to  an  irritating 
cough.  The  "paradoxical  pulse,"  small  and  feeble  durmg  inspira- 
tion, is  occasionally  to  be  seen,  but  is  by  no  means  peculiar  to  this 
condition  and  has  no  considerable  diagnostic  importance. 

(4)  Inspection  and  palpation  usually  help  us  very  little,  but  two 
points  are  occasionally  demonstrable  by  these  methods : 

(a)  A  smoothing  out  of  the  intercostal  depression  in  the  precor- 
dial region,  especially  near  the  right  border  of  the  sternum  between 
the  third  and  the  sixth  ribs. 

(h)  A  progressive  diminution  of  the  intensity  of  the  apex  im- 
pulse until  it  may  be  altogether  lost.  If  this  change  occurs  while 
the  patient  is  under  observation,  and  especially  if  the  apex  impulse 
reapjpears  or  becomes  more  distinct  when  the  patient  lies  on  the 
right  side,  it  is  of  considerable  diagnostic  value.  In  conditions 
other  than  pericardial  elfusion,  the  apex  impulse  becomes  less  visible 
in  the  right-sided  decubitus. 

Differential  Diagnosis. 

(1)  Our  chief  difficulty  is  to  distinguish  the  disease  from  hyper- 
trophy and  dilatation  of  the  heart.  In  the  latter,  which  often  com- 
plicates acute  articular  rheumatism  with  or  without  i)lastic  pericar- 
ditis, the  apex  impulse  is  often  very  indistinct  to  sight  and  touch 
as  in  pericardial  effusion.  But  the  area  of  dulness  is  less  likely  to 
extend  beyond  the  apex  impulse  to  the  left  or  to  modify  the  cardio- 
hepatic  angle,  or  to  shift  when  the  patient  lies  on  the  right  side. 
Pressure  symptoms  are  absent,  and  there  are  no  areas  of  broncho- 
vesicular  breathing  Avith  tympanitic  resonance  under  the  left  clavicle 
or  in  the  axilla.  Yet  not  infrequently  these  differentiae  do  not 
serve  us,  and  the  diagnosis  can  be  made  only  by  puncture. 

(2)  I  have  twice  known  cases  of  encapsulated  empyema  mistaken 
for  pericardial  effusion.  In  one  case  a  needle  introduced  in  the 
fifth  intercostal  space  below  the  nipple  drew  pus  from  what  turned 
out  later  to  be  a  localized  purulent  pleurisy,  but  the  diagnosis  was 
not  made  until  a  rib  had  been  removed  and  the  region  thoroughly 
explored.      It  is  not  rare  for  pleuritic    effusions    to  gather  first 


216     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

in  this  situation,  viz.,  just  ovitsicle  the  apex  impulse  in  the  left 
axilla. 

Such  effusions  may  gi-avitate  very  slowly  to  the  bottom  of  tlie 
pleural  cavity  or  may  become  encapsulated  and  remain  in  their 
original  and  veiy  deceptive  position.  lu  such  cases  the  signs  of 
compression  of  the  left  lung  are  similar  to  those  produced  by  a 
pericardial  effusion,  and  the  results  of  iiunctures  may  be  equivocal 
as  in  the  case  just  mentioned.  If  there  is  au)/  dulness,  even  a  very 
narrow  zone,  in  the  left  axilla  between  the  fifth  and  eighth  ribs, 
though  there  be  none  in  the  back,  the  likelihood  of  pleurisy  should 
be  suggested. 

As  between  pleuritic  and  pericardial  effusion  the  presence  of  a 
good  pulse  and  the  absence  of  marked  dyspnoea  favors  the  former. 
In  the  two  cases  above  referred  to  in  which  encapsulated  pleurisy 
was  mistaken  for  pericarditis,  the  general  condition  of  the  jDatient 
stmck  me  at  the  time  as  surprisingly  good  for  pericarditis. 

If  botJi  pleurisy  and  pericarditis  are  present,  the  area  of  peri- 
cardial dulness  is  not  characteristic  until  the  pleuritic  fluid  has  been 
drawn  off.  The  persistence  of  dulness  in  the  cardio-hepatic  angle 
and  beyond  the  apex  beat  after  a  left  pleurisy  has  been  emptied  by 
tapping,  and  after  the  heart  has  had  time  to  return  to  its  normal 
position,  should  make  us  suspect  a  pericardial  effusion. 

Despite  the  utmost  care  and  thoroughness  in  physical  examina- 
tion, many  cases  of  pericardial  effusion  go  unrecognized,  especially 
in  infants,  in  elderly  persons,  or  when  the  lung  borders  are  adher- 
ent to  the  pericardium  or  to  the  chest  wall. 

In  the  rheumatic  attacks  of  children,  it  should  be  remembered 
that  pericarditis  is  even  more  common  than  endocarditis. 

Adherent  Pericardium . 

In  the  majority  of  cases  the  diagnosis  cannot  be  made  during 
life,  unless  the  pericardium  is  adherent,  not  only  to  the  heart,  but 
to  the  Avails  of  the  chest  as  well.  Wlien  this  combination  of  peri- 
carditis with  chronic  mediastinitis  is  present,  the  diagnosis  may  be 
suggested  by 

(a)  A  systolic  retraction  of  the  chest  wall  in  the  region  of  the 


DISEASES  OF  THE  PERICARDIUM.  217 

apex  impulse  at  the  base  of  the  left  axilla  and  in  the  region  of  the 
eleventh  and  twelfth  ribs  in  the  left  back  (Broadbent's  sign).  Such 
retraction  is  more  marked  during  a  deep  inspiration.  (It  should 
be  remembered  that  systolic  retraction  of  the  interspaces  in  the 
vicinity  of  the  aj^ex  is  very  commonly  seen  in  cases  of  cardiac  hy- 
pertrophy from  any  cause,  owing  to  the  negative  pressure  produced 
within  the  chest  by  the  contraction  of  a  powerful  heart.)  A  quick 
rebound  of  the  cardiac  apex  at  the  time  of  diastole  (the  diastolic 
shock)  is  said  to  be  characteristic  of  pericardial  adhesions,  but  is 
often  absent. 

(h)  Collapse  of  the  cervical  veins  during  diastole  has  been  no- 
ticed by  Friedreich,  and  the  paradoxical  pulse,  above  described,  is 
said  to  be  more  marked  in  adherent  pericardium  than  in  any  other 
known  condition.  Most  recent  writers,  however,  place  no  reliance 
upon  it. 

(c)  WTien  the  lungs  are  adherent  to  the  pericardium  or  to  the 
chest  wall,  as  is  not  uncommonly  the  case,  the  absence  of  the  phrenic 
phenomenon  (Litten's  signs)  and  of  any  respiratory  excursion  of 
the  pulmonary  margins  may  be  demonstrated.  Since  pericardial 
adhesions  are  most  often  due  to  tuberculosis,  the  discovery  of  tu- 
berculosis in  the  lung  or  elsewhere  may  be  of  aid  in  diagnosis. 

(d)  Broadbent  considers  that  the  absence  of  any  shift  in  the 
position  of  the  apex  beat,  with  respiration  or  change  of  patient's 
position,  is  an  important  point  in  favor  of  mediastino-pericarditis. 
In  health  and  in  valvular  or  parietal  disease  of  the  heart,  the  apex 
beat  will  swing  from  one  to  two  inches  to  the  left  when  the  patient 
lies  on  his  left  side,  and  the  descent  of  the  diaphragm  during  full 
inspiration  lowers  the  position  of  the  cardiac  impulse  considerably. 

(e)  The  presence  of  hypertrophy  or  dilatation  affecting  espe- 
cially the  right  side  of  the  heart,  and  not  accounted  for  by  the 
existence  of  any  disease  of  the  cardiac  valves,  of  the  lung,  or  of 
the  kidney,  should  make  us  suspect  pericardial  and  mediastinal 
adhesions.  Such  adhesions  embarrass  especially  the  right  ven- 
tricle, because  it  is  the  right  ventricle  far  more  than  the  left  which 
becomes  attached  to  the  chest  wall.  The  left  ventricle  is  more 
nearly  free. 


218     PHYSICAL  DIAGXOSIS   OF  DISEASES  OF  THE  CHEST. 

(f)  Since  the  space  enclosed  by  the  divergent  costal  cartilage 
just  below  the  ensiform  is  but  loosely  associated  Avith  the  cen- 
tral tendon  of  the  diaphragm,  Broadbent  looks  especially  at  thi'i 


Fig.  115.  FIG.  116. 

Figs.  115, 116.— Adherent  Pericardium,  Ascites. 

point  for  evidence  of  mediastinal  or  pericardial  adhesions,  the 
effect  of  Avhich  is  to  arrest  completely  the  slight  respiratory  move- 
ments of  this  part  of  the  abdominal  wall. 

([/)  Adherent  pericardium,  occurring  as  a  part  of  a  widespread 


DISEASES   OF  THE  PERICARDIUM.  219 

chain  of  fibrous  x>i"ocesses  involving  the  pleura,  the  mediastinum, 
and  the  peritoneum,  may  give  rise  in  young  persons  to  a  train  of 
symptoms  and  signs  suggesting  cirrhosis  of  the  liver.  Ascites 
collects,  the  liver  is  enlarged,  yet  there  are  no  signs  in  the  heart, 
kidneys,  or  blood  sufficient  to  explain  the  condition.  In  any  such 
case  adherent  pericardium  should  be  considered.  Figs.  115  and  IIG 
show  the  appearance  in  cases  of  this  kind  in  which  the  diagnosis 
was  verified  by  autoj^sy. 

Snininarij. 

The  diagnosis  of  adherent  pericardium  with  chronic  mediastini- 
tis  is  suggested  by 

i/i')  Systolic  retraction  of  the  lower  intercostal  spaces  in  the 
left  axilla  and  in  the  left  back,  followed  by  a  diastolic  rebound. 

(h)  The  absence  of  any  change  in  the  j^osition  of  the  apex  im- 
pulse with  respiration  or  change  of  position. 

((')  The  presence  of  hypertrophy  and  dilatation  of  the  right 
ventricle  without  obvious  cause. 

(d)  The  absence  of  any  respiratory  excursion  of  the  lung  bor- 
ders near  the  heart  and  of  the  abdominal  wall  at  the  costal  angle. 

{c)  The  presence  of  signs  like  those  of  hepatic  cirrhosis  in  a 
young  person  and  without  any  obvious  cause. 


CHAPTER   X. 

THOEACIC  A^^EUEISM. 
Aneurism   of  the  Thoracic  Aorta. 

For  clinical  purposes  thoracic  aneurisms  may  be  divided  into 
the  diffuse  and  the  saccular.  Saccular  aneurisms  of  the  ascending 
or  descending  portion  of  the  arch  of  the  aorta  are  apt  to  penetrate 
the  chest  wall,  while  aneurism  of  the  transverse  aorta  or  diffuse 
dilatations  of  the  Avhole  aortic  arch  are  more  likely  to  extend  within 
the  chest  without  erodmg  the  thoracic  bones.  Practically  any 
aneurism  which  penetrates  tlie  thoracic  bones  may  be  inferred  to 
be  saccular,  but  if  no  such  penetration  takes  place,  it  may  be  im- 
possible to  make  out  whether  the  dilatation  is  diffuse  or  circum- 
scribed.    I  shall  consider: 

I.  The  signs  of  the  presence  of  aneurism. 

II.  The  evidences  of  its  seat. 

Inspection  and  imlpation  give  us  most  of  the  important  informa- 
tion in  the  diagnosis  of  aneurism.  The  patient  should  be  placed  in 
the  position  shown  in  Fig,  117,  so  that  the  light  will  strike  obliquely 
across  the  surface  of  the  chest,  and  the  observer  should  be  so  placed 
that  his  eyes  are  as  nearly  as  j^ossible  at  the  level  at  that  part  of 
the  chest  at  which  he  hopes  to  see  pulsation. 

In  the  majority  of  cases  of  aneurism  some  ahnomnal  indsatlon 
may  be  made  out  either  to  the  right  of  the  sternum  in  front  or  in 
Abnormal  ^^®  region  of  the  left  scapula  behind.  If  the  aneur- 
Pulsation.  ism  is  large,  a  considerable  area  of  the  chest  wall  may 
be  lifted  with  each  beat  of  the  heart;  with  smaller  growths  the 
pulsating  area  may  be  small  and  sharply  circumscribed.  Not  in- 
frequently  an  abnormal  i)ulsation  at  the  sternal  notch  or  in  the 


THORACIC  ANEURISM. 


221 


neck  may  be  observed.  Other  causes  of  abnormal  pulsations  in 
the  chest,  such  as  dislocation  or  uncovering  of  the  heart,  must  of 
course  be  excluded.  Pulsations  due  to  aneurism  can  sometimes 
be  distinctly  seen  to  occur  later  than  the  apex  impulse  of  the  heart. 

Palpation  controls  tiie  results  of  inspection,  but  at  times  a  pul- 
sation may  be  seen  better  than  felt ;  at  others  may  be  felt  better 
than  seen.  Bkiianual  palpation — one  hand  over  the  suspected  area 
in  front  and  one  in  a  corresponding  position  behind— is  useful. 

If  the  aneurism  involves  the  ascending  portion  of  the  aortic 


Fig.  117.— Positiou  When  Looking  for  Slight  Aneurlsmal  Pulsatloa. 


arch,  it  is  likely  sooner  or  later  to  erode  the  right  margin  of  the 
sternum  and  the  adjacent  parts  of  the  second  or  third  costal  car- 
tilages and  appear  externally  as  a  round  swelling  in 
Tumor.  ^j^j^j^  j^  systolic  pulsation  is  to  be  seen  and  felt.  This 
pulsation  is  almost  always  distinctly  expansile  in  character,  and 
differs  in  this  respect  from  the  up-and-down  motion  which  may 
be  communicated  to  a  tumor  of  the  chest  wall  by  the  beating  of 
a  normal  aorta.  The  tumor  is  usually  firm,  rarely  soft,  and  may 
be  as  hard  as  any  variety  of  malignant  new  growth.     Occasionally 


222    PHYSICAL  DIAGNOSIS   OF  DISEASES  OF  THE  CHEST. 


the  thickness  of  the  lamellated  clot  withhi  it  is  so  great  that  no 
pulsations  are  transmitted  to  the  surface. 

AVhether  the  aneurism  penetrates  the  chest  or  not,  it  is  often 
.  possible  to  feel  over  it  a  vlbratinrj  thrill,  usually  sijs- 

tolic  in  time.     If  the  la3'er  of  lamellated  clot  in  the 
sac  is  very  thick,  the  thrill  is  less  apt  to  be  felt. 

More  important  in  diagnosis  is  a  diastolic  shock  or  tap  which  is 
appreciated  by  laying  the  palm  of  the  hand  lightly  over  the  affected 


FiO.  118.— Aneurbmal  Tumor  (^1;.    The  arrow  U  points  to  a  guuimatous  swelling  neartheea- 
siform  cartilage.    The  radiographic  appearances  of  this  case  are  shown  below  (Fig.  121). 


area.  This  diastolic  shock  is  due  to  the  recoil  of  the  blood  in  the  di- 
lated aorta,  and  is  one  of  the  most  important  and  characteristic  signs 
Diastolic  ^^  aneurism.  As  the  wall  of  the  sac  becomes  weaker. 
Shock,  the  intensity  of  this  shock  diminishes.  This  diastolic 
shock  may  be  appreciated  over  the  trachea  also,  and  is  thought  by 
some  to  liave  even  more  significance  when  felt  in  this  situation. 

Of  special  importance  in  aneurism  of  tlie  transverse  arch  is  the 
sign  known  as  the  tracheal  tuy.     The  arch  of  the  aorta  runs  over 


THORACIC  ANEURISM. 


223 


the  left  primary  bronchus  in  such  a  ■way  that  when  the  aorta  is 
dilated,  the  bronchus  is  pressed  upon  with  each  expansile  pulsation 
Tracheal  of  the  artery.  This  systolic  pressure  transmitted  to 
Tug.  the  trachea  j^roduces  a  distinct  downward  tug  upon  it 
with  each  systole  of  the  heart.  The  tug  is  best  felt  by  making  the 
patient  throw  back  his  head  so  as  to  put  the  trachea  upon  a  stretch. 
The  physician  then  stands  beliind  him  and  gently  presses  the  tips 
of  the  fingers  of  both  hands  up  under  the  lower  border  of  the  cri- 


FIG.  119.— Aneurism  Tumor  Perforating  the  Sternum  at  A.    At  B  tliere  is  a  gummatous  mass. 
(See  below.  Fig.  131,  a  radiograpli  of  this  case;. 

coid  cartilage.  In  feeling  thus  for  the  tracheal  tug  as  transmitted 
to  the  cricoid  cartilage  certain  precautions  must  be  observed : 

{a)  One  must  distinguish  the  tracheal  tug  from  a  simple  pulsa- 
tion transmitted  to  the  superficial  tissues  by  the  vessels  under- 
neath. Such  pulsation  makes  the  tissues  move  out  and  in  rather 
than  up  and  down. 

{h)  A  tracheal  tug  felt  only  during  inspiration  has  no  patho- 
logical significance  and  is  frequently  present  in  health. 

While  preparing  to  try  for  the  tracheal  tug  we  may  notice 
whether  there  is  any  dislocation  of  the  trachea,  as  shown  by  the 


224    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

displacement  of  Ad?.m's  apple.  Other  and  less  important  signs  of 
aneurism,  which  are  due  to  the  pressure  of  the  dilated  aorta  upon 
the  nerves  or  vessels  of  the  mediastmum,  are : 

(1)  Inequality  of  the  pupils. 

(2)  Inequality  of  the  radial  pulses. 

(3)  CEdema  and  cyanosis  of  one  arm  or  of  one  side  of  the  neck 
and  head. 

(4)  Pain  in  one  arm  from  the  pressure  of  an  aneurism  involving 
the  subclavian  artery  upon  the  brachial  plexus. 

(5)  Clubbing  of  the  fingers  of  one  hand  (rare). 

(6)  Prominence  of  one  eye  (rare). 

(7)  Flushing  or  sweating  of  one  side  of  the  face  (very  rare). 
Contraction  or  dilatation  of  the  pupil  is  due  to  an  irritative  or 

paralytic  affection  of  the  sympathetic  nerves.  This  symptom  is 
much  commoner  than  the  other  eifect  of  pressure  upon  the  sympa- 
thetic nerves ;  namely,  flushing  or  SAveating  of  one  side  of  the  face. 

In  comparing  the  pulses  in  the  two  radials  we  must  bear  in  mind 
the  possibility  of  a  congenital  difference  between  them,  due  to  a 
difference  either  in  the  size  of  the  arteries  or  in  their  position,  and 
also  that  a  tumor  pressing  on  the  subclavian  may  affect  the  pulse 
exactly  as  an  aneurism.  The  pulse  wave  upon  the  affected  side 
(most  often  the  left)  may  be  either  less  in  volume  or  later  in  time 
than  the  wave  in  the  other  radial  artery,  according  as  the  pulse 
wave  is  actually  delayed  in  the  aneurismal  sac  or  merely  diminished 
by  it.  In  marked  cases  the  pulse  upon  the  affected  side  may  be 
nearly  or  quite  absent.  On  the  other  hand  the  inequality  of  the 
pulses  may  be  so  slight  that  the  sphygmograph  fias  to  be  employed 
to  demonstrate  differences  in  the  shape  of  the  wave  not  perceptible 
to  the  fingers. 

Exammation  of  the  heart  itself  may  show  some  dislocation  of 
the  organ  to  the  left  and  downward,  owing  to  the  direct  pressure 
of  the  aneurismal  sac. 

II.   Percussion. 

If  the  aneurism  is  deep-seated,  the  results  of  percussion  are 
negative.     If,  on  the  other  hand,  it  be  situated  immediately  be- 


THORACIC  ANEURISM. 


225 


neath  the  sternum  or  close  under  the  thoracic  wall,  an  area  of  dul- 
ness,  not  present  in  the  normal  chest,  may  be  majaped  out.  The 
outlines  most  commonly  seen  in  such  cases  are  shown  in  Fig.  120. 
When  the  aneurism  involves  the  descending  aorta,  an  area  of  dulness 
may  be  found  in  the  region  of  the  left  scapula  or  below  it,  and  pul- 
sation may  be  detected  in  the  same  area. 

III.  Auscultation. 

The  signs  revealed  by  auscultation  are  not  of  much  diagnostic 
value  as  a  rule.     In  about  one-half  of  the  cases  of  sacculated  aneu- 


Aneurismal 
duluetis.    " 


Heart  dulness. 


Liver  dulness^' 


Fig.  120.— Diagram  of  Percussion  Dulness  in  Aortic  Aneurism. 

rism  there  are  no  sounds  or  murmurs  to  be  heard  over  the  tumor. 
In  other  cases  a  systolic  murmur,  the  audible  counterpart  of  the 
vibratile  thrill,  may  be  heard  over  the  area  of  pulsation,  tumor,  or 
dulness  corresponding  to  the  aneurismal  sac.  This  systolic  mur- 
mur may  be  due  to  many  causes  other  than  aneurism,  and  has  noth- 
ing characteristic  about  it.  A  similar  systolic  sound  is  sometimes 
heard  over  the  trachea  (Drummond's  sign)  or  in  the  mouth,  if  the 
patient  closes  his  lips  around  the  pectoral  extremity  of  the  steth- 
oscope (Sansom's  sign). 

A  loud,  low-j)itched  diastolic  sound,  corresponding  to  the  pal' 
15 


226    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

pable  diastolic  shock,  is  generally  to  be  heard  in  the  aortic  region. 
This  diastolic  sound,  which  is  probably  not  produced  by  the  aortic 
valves,  is  remarkably  deep-toned  and  loud,  and  is,  on  the  Avhole,  the 
most  important  sign  of  aneurism  revealed  by  auscultation. 

If  a  portion  of  either  lung  is  directly  pressed  upon  by  the  an- 
eurismal  sac,  we  may  have  the  signs  of  condensation  of  the  lung 
in  the  area  pressed  upon  (slight  dulness,  broncho-vesicular  breath- 
ing, and  exaggerated  voice  sounds).     If  one  of  the  primary  bronchi 


From  the  from. 


From  behind. 


Fig.  121.— Radiograph  of  Case  whose  Photograph  Is  Reproduced  as  Figs.  118  and  119.  In  the 
right-hand  cut  are  shown  the  appearances  seen  from  behind.  The  left-hand  cut,  -.4,  A, 
aneurismal  sac;  B,  heart  displaced ;  C,  liver  (not  in  focus). 


is  pressed  ui)on,  as  occasionally  happens,  atelectasis  of  the  corre- 
sponding lung  may  be  manifested  by  the  usual  signs  (dulness,  ab- 
sence of  tactile  fremitus  and  of  respiratory  and  vocal  sounds). 

Since  aneurism  is  frequently  associated  with  regurgitation  at 
the  aortic  valve,  a  diastolic  murmur  is  not  infrequently  to  be 
heai-d. 

If  the  aneurismal  sac  is  of  very  great  size,  the  pulse  wave  in 
the  femorals  may  be  obliterated,  as  happened  in  a  case  described 
by  Osier. 


THORACIC  ANEURISM. 
lY.  Hadioscojyy. 


227 


With  the  fluoroscope  and  through  photography  one  can  often 
make  out  a  shadow  corresponding  to  the  position  of  the  aneurism. 


Dilated  aortic 
arch. 


Hypertrophied 
heart. 


Fig.  122.— Aortic  Regurgitation  with  Diffuse  Dilatation  of  the  Aortic  ArcU.    Front  view. 

The  position  of  the  shadow  is  best  explained  by  reference  to  Figs 
121,  122,  and  123. 

Summary. 

The  most  important  signs  of  aneurism  are  : 

1.  Afmorynal  jyiilsatmi— visible  or  palpable 

2.  Tumor  over  which  a 

3.  Thrill  and  a 


228     PHYSICAL  DIAGyOSIS  OF  DISEASES  OF  THE  CHEST. 

4.  Diastolic  shock  may  be  felt. 

5.  Tracheal  tug. 

6.  Pressure  signs  (unequal  jiulses,  pupils,  hoarseness,  j)ain,  etc.)= 

7.  Duliiess  on  percussion  over  the  suspected  area. 

8.  Loud,  low-pitched  aortic  second  sound. 

9.  Systolic  murmur  (least  important  of  all). 


Aneurlsmalsac. 


Heart  displaced 
downward  by 
the  aneurism. 


Fio.  12).— Extensive  Aortic  Aneurism  Displacing  the  Heart. 

10,  Radio.<icopif  may  demonstrate  a  shadow  higher  up  than  that 
corresponding  to  the  heart  and  extending  beyond  that  jaroduced  by 
the  sternum,  spinal  column,  and  great  vessels. 

Diagnosis  of  the  Seat  of  the  Lesion. 

(a")  Aneurism  of  the  ascending  arch  generally  approaches  or 
penetrates  the  chest  wall  in  the  -sdcinity  of  the  second  right  inter- 
costal space  near  the  sternum.     Previous  to  perforating  the  thoracic 


THORACIC  ANEURISM.  229 

parietes,  the  growth  of  the  aneurism  may  give  rise  to  pain,  pulsa- 
tion, and  dulness  and  thrill  in  this  region. 

(h)  Aneurism  of  the  transverse  arch  or  diffuse  dilatation  of  the 
aorta,  sueh  as  usually  occurs  in  long-standing  cases  of  aortic  regur- 
gitation, may  not  give  rise  to  any  visible  pulsation  of  the  chest 
wall,  and,  if  deep-seated,  need  not  produce  any  abnormal  dulness 
on  percussion.  In  such  cases  an  aneurism  is  to  be  recognized,  if 
at  all,  by  evidences  of  pressure  on  the  nerves  or  vessels  of  the  medi- 
astinum (cough,  aphonia,  inequality  of  the  pupils,  tracheal  tug, 
etc.). 

(c)  Aneurism  of  the  descending  aorta  gives  rise  usually  to  severe 
and  persistent  pain  in  the  back,  which  radiates  along  the  intercos- 
tal nerves  or  downward.  Other  pressure  symptoms  are  not  marked, 
but  in  advanced  cases  an  area  of  abnormal  dulness  and  pulsation 
may  be  found  in  the  region  of  the  left  scapula  or  below  it. 

(d)  If  the  innominate  artery  or  one  of  the  carotids  is  involved, 
we  usually  find  a  pulsating  lump  in  the  region  of  one  or  the  other 
claviculo-sternal  joint  or  at  the  root  of  the  neck,  and  the  trachea 
may  be  displaced  to  one  side.  If  the  subclavian  is  involved  or 
pressed  upon,  there  may  be  pain  and  oedema  in  the  corresponding 
arm. 

Differential  Diagnosis. 

(a)  Some  writers  draw  a  distinction  between  the  diffuse  dilata- 
tion of  the  aortic  arch,  which  sooner  or  later  complicates  almost 
every  case  of  incompetency  of  the  aortic  valves,  and  saccular  aneu- 
rism of  the  transverse  portion  of  the  aorta.  Clinically,  such  dis- 
tinction seems  to  be  impossible,  although  if  symptoms  resemblmg 
those  of  aneurism  gradually  develop  in  a  case  of  aortic  regurgita- 
tion, one  may  suspect  that  the  dilatation  of  the  aorta  is  merely 
part  of  the  distention  of  the  whole  arterial  tree,  which  aortic  regur- 
gitation tends  to  produce. 

(h)  Aneurism  is  not  infrequently  mistaken  for  aoi-tic  stenosis,  in 
which  a  systolic  murmur  and  thrill,  similar  to  those  occurring  in 
aneurism,  are  to  be  heard  over  the  region  of  the  aortic  arch.  From 
aortic  stenosis  aneurism  is  distinguished  by  the  fact  that  it  does 


230     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

not  produce  characteristic  changes  in  the  piilse,  and  by  the  presence 
of  some  one  of  the  symptoms  above  described,  such  as  tracheal 
tug,  pressure  symptoms,  abnormal  area  of  percussion  dulness,  etc. 

(c)  Simple  dynamic  throbbing  of  a  normal  aortic  arch  similar 
to  that  which  occurs  in  the  abdominal  aorta  may  lift  the  chest  wall 
so  as  to  simulate  aneurism.  The  other  positive  symptoms  and 
signs  of  aneurism  are,  however,  absent. 

(d)  Pulmonary  tuberculosis  or  cancer  of  the  oesophagus,  produc- 
ing as  they  may  substernal  jjain,  cough,  and  aphonia  by  pressure 
upon  mediastinal  structures,  have  been  mistaken  for  aneurism, 
from  which,  however,  they  may  be  distinguished  by  the  absence  of 
the  positive  signs  above  described,  by  the  more  rapid  emaciation 
of  the  patient,  and  by  the  positive  evidences  of  cancer  or  tubercu- 
losis. 

(e)  Empyema  necessitatis  may  produce  a  pulsating  tumor  like 
that  of  aneurism  and  the  area  of  dulness  may  be  similar,  but  there 
is  no  diastolic  shock,  no  tactile  thrill  or  murmur,  and  the  history 
of  the  case  is  usually  very  different  from  that  of  aneurism.  It  is 
perfectly  safe  to  insert  a  fine  hollow  needle  in  doubtful  cases.  Xo 
serious  hemorrhage  results  if  aneurism  is  present,  and  the  diagnosis 
and  treatment  may  be  greatly  assisted. 

(/)  Mediastinal  tumors  are  sometimes  almost  indistinguishable 
from  aneurism  during  life.  They  may  produce  a  more  intense  and 
widespread  dulness  which  is  usually  in  the  median  line,  while  the 
dulness  of  aneurism  is  oftener  at  one  side.  The  pulsation  transmit- 
ted to  a  tumor  by  the  heart  has  not  the  expansile  character  of  aneu- 
rismal  pulsation.  Tumors  are  not  associated  with  any  diastolic 
shock,  rarely  with  a  tracheal  tug. 

The  course  of  most  mediastinal  tumors  is  progressive  and  at- 
tended by  great  cachexia,  while  the  symptoms  of  aneurism  are  often 
more  or  less  intermittent,  and  unless  pain  i  i  severe  there  is  no  such 
emaciation  or  anaemia  as  is  commonly  seen  with  mediastinal  tu- 
mors. Pressure  symptoms  may  be  the  same  in  both  diseases,  but 
are  usually  more  marked  with  mediastinal  growths.  A  metastatic 
nodule  over  the  clavicle  sometimes  betrays  the  presence  of  a  pri- 
mary focus  within  the  chest. 


THORACIC  ANEURISM.  231 

((/)  Retraction  of  the  rUjht  lung  (fibroid  phthisis),  with  or  without 
displacement  of  the  heart  toward  the  diseased  side,  may  uncover 
the  heart  so  as  to  produce  some  of  the  signs  of  aneurism,  i.e.,  pul- 
sation and  dulness  in  the  upper  right  intercostal  spaces  near  the 
sternum,  with  a  loud  aortic  second  sound  and  sometimes  a  systolic 
murmur  in  the  dull  area. 

The  history  of  the  case  and  a  careful  examination  of  the  limgs 
usually  suffice  to  set  us  right. 

{h)  Dilatation  of  the  heart  may  be  so  extreme  that  pulsation 
and  percussion  duhiess  appear  in  the  characteristic  aneurismal  area 
to  the  right  of  the  sternum,  especially  if  there  is  solidification  of 
the  left  lung.  But  the  pulse  is  in  such  cases  much  weaker  and 
more  irregular  than  is  to  be  expected  in  uncomplicated  cases  of  aortic 
aneurism,  and  the  history  of  the  case  is  usually  decisive. 


PART  III. 

DISEASES   OF   THE    LUNGS. 


CHAPTER   XI. 

BKONCHITIS,  PN^EUMONIA,  TUBERCULOSIS. f" 

I.  Tracheitis. 

In  connection  with  bronchitis  or  as  a  forerunner  thereof,  inflam- 
mation of  the  trachea  is  not  uncommon.  It  gives  rise  to  no  char- 
acteristic physical  signs,  but  is  to  be  suspected  when  the  patient 
complains  of  cough  with  imin  over  the  upper  portion  of  the  sternum. 

Bronchitis. 

Inflammation  of  the  larger  bronchial  tubes  is  not  often  the 
cause  of  any  definite  physical  signs,  but  with  every  paroxysm  of 
coughing  the  patient  may  feel  pain  in  an  area  corresponding  ex- 
actly to  the  anatomical  position  of  the  primary  bronchi.  I  have 
seen  patients  indicate  most  accurately  the  situation  of  the  large 
tubes  when  pointing  out  the  position  of  pain  produced  by  coughing. 

In  the  vast  majority  of  cases  of  acute  bronchitis  the  smaller 
bronchi  are  involved,  and  the  swelling  of  their  walls,  with  or  with- 
out exudation,  is  manifested  by  the  following  physical  signs : ' 

(1)  Diminution  in  the  intensity  of  vesicular  breathing  over  the 
area  affected  (rarely  in  the  earliest  stages  the  breath  sounds  are 
exaggerated  and  harsh,  especially  in  the  upper  portions  of  the 
chest). 

'  Bronchitis  may  exist  without  rales,  but  cannot  be  diagnosed  without 
them.     Occasionally  they  are  present  onlyin  the  early  morning. 


234    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

(2)  Jiciles,  which  are  squeaking  or  piping  over  bronchi  which 
are  narrowed  without  any  considerable  amount  of  exudation,  as  is 
the  case  in  the  earliest  stages  of  many  cases,  and  bubbling,  crack- 
ling, or  clicking  in  later  stages,  when  watery  or  viscid  exudation  is 
present  in  the  tubes.  The  calibre  of  the  bronchi  affected  can  be 
estimated  from  the  coarseness  or  fineness  of  the  rales.  Low-pitched 
groaning  sounds  point  to  a  stenosis  of  a  relatively  large  bronchus, 
while  squeaking  and  whistlmg  sounds  are  usually  produced  in  the 
smaller  tubes.  Large,  bubbling  rales  are  much  less  often  heard 
than  the  finer,  cracklmg  variety.  The  latter  are  produced  in  the 
smallest  tubes,  the  former  in  the  larger  variety. 

Simple  non-tuberculous  bronchitis  is  almost  invariably  hUaterul 
or  symmetrical,  and  affects  most  often  the  lower  two-thirds  of  the 
lungs,  leaving  the  apices  relatively  free.  It  is  almost  never  con- 
fined to  an  apex.  When  rales  are  to  be  heard  on  one  side  of  the 
chest  only,  and  when  they  persist  in  the  same  spot  for  days  and 
weeks,  tuberculosis  is  always  to  be  suspected,  especially  if  the 
rales  are  localized  at  the  summit  of  one  or  both  lungs.  It  should 
never  be  forgotten  that  the  tubercle  bacillus  is  caj^able  of  exciting 
a  bronchitis  indisthiguishable  from  other  varieties  of  bronchitis, 
except  by  its  tendency  to  show  itself  at  the  apex  of  the  lung  and 
on  one  side  only ;  most  cases  of  pulmonary  tuberculosis  begin  in 
this  way 

The  only  other  variety  of  bronchitis  which  is  often  unilateral  is 
that  due  to  influenza  bacillus.  In  the  course  of  a  case  of  influenza, 
a  imilateral  localized  bronchitis  not  infrequently  occurs.  Over  a 
patch  of  lung,  perhaps  the  size  of  the  palm  of  the  hand,  fine,  moist 
rales  may  persist  for  weeks,  finally  clearing  up  only  after  the  pa- 
tient has  resumed  his  ordinary  occupation.  Doubtless  such  local- 
ized patches  of  bronchitis  are  often  accompanied  by  foci  of  lobular 
pneumonia  too  small  to  be  detected  by  our  present  methods  of 
physical  examination. 

Percussion  dulness  is  absent  in  bronchitis  except  near  the  end 
of  fatal  cases,  when  the  lung  is  stuffed  with  mucus  and  pus,  or 
when  atelectasis  has  occurred  owing  to  extensive  plugging  of  the 
lai'ger  bronchi.     These  events  are  rarely  seen,  and  in  general  the 


BRONCHITIS,  PNEUMONIA,   TUBERCULOSIS.  235 

negative  results  of  percussion  are  of  great  value  in  excluding  sol- 
idification or  fluid  exudation. 

Occasionally  percussion  resonance  may  be  increased  owing  to 
a  slight  temporary  overdistention  of  the  air  vesicles  from  coughing. ' 

Inspection  usually  shows  little  or  nothing  of  diagnostic  impor- 
tance in  acute  bronchitis.  Long-standing  cases,  complicated  as 
they  almost  invariably  are  by  emphysema,  present  changes  in  the 
shape  of  the  thorax ;  but  these  are  due  to  the  emphysema  rather 
than  to  the  bronchitis.  In  children  acute  bronchitis  sometimes 
involves  so  many  of  the  smaller  bronchi  that  dyspnoea  and  use  of 
accessory  muscles  of  respiration  are  notable.  But  this  usually 
means  atelectasis,  broncho-pneumonia,  or  laryngeal  spasm,  in  addi- 
tion to  the  bronchitis. 

From  violent  coughing  the  jugulars  may  be  distended,  but  no 
systolic  pulsation  occurs  in  them. 

Voice  sounds  and  tactile  fremitus  are  normal. 

Differential  Diagnosis. 

(Edema  of  the  lung  and  bronchial  asthma  are  the  only  pathologi- 
cal processes  (except  hemorrhage  into  the  lung  substance)  which 
give  rise  to  signs  like  those  of  bronchitis. 

(1)  In  mdema  of  the  lung,  or  puhnonary  apoplexy,  one  may 
find,  as  in  simple  bronchitis,  a  diminished  vesicular  breathing  with 
crackling  rales,  but  oedema  of  the  lung  is  almost  always  best  marked 
in  the  dependent  portions;  that  is,  in  the  posterior  parts  of  the 
lung  if  the  patient  has  been  lying  upon  the  back,  or  in  the  lower 
lobes  if  he  has  been  sitting  up.  The  rales  of  oedema  are  always 
moist,  are  more  uniform  in  size  when  compared  to  those  of  bron- 
chitis, and  are  never  mingled  with  squeaking  or  groaning  sounds. 
The  recognition  of  a  cause  for  the  oedema,  for  example  a  non-com- 
pensated heart  lesion,  materially  aids  in  the  diagnosis. 

(2)  Bronchial  asthma  or  spasm  of  the  finer  bronchi  produces  dry 
squeaking  and  groaning  sounds  sunilar  to  those  heard  in  the  earlier 

1  In  children  examined  dui-ing  a  crying-spell  a  cracked-pot  sound  can 
usually  be  elicited  by  percussion.  This  is  in  no  way  characteristic  of  bron-. 
chitis  and  can  often  be  obtained  in  healthy  infants. 


236    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 


stages  of  many  cases  of  bronchitis.  But  in  bronchial  asthma  the 
rales  are  chiefly  exjnratory,  and  expiration  is  prolonged  and  inten- 
sified.   Moreover,  the  inhalation  of  a  few  drops  of  amyl  nitrite  will 

temporarily  dispel  rales  due  to  bronchial 
spasm,  while  on  the  rales  of  dry  bronchitis 
it  has  no  effect  (Abrams). 

(3)  Broncho-pneurnonia.  In  many 
cases  of  lobular  or  broncho-pneumonia  the 
physical  signs  are  exclusively  those  of  the 
coexisting  bronchitis.  In  such  cases  the 
diagnosis  of  bronchitis  is  not  wrong,  but 
does  not  cover  the  whole  ground.  I  shall 
discuss  further  under  broncho-pneumonia 
the  evidence  which  leads  us  to  suspect 
that  somethmg  more  than  bronchitis  is 
present. 

(4)  31i(scle  sounds.  Under  certain 
circumstances  (cold,  nervousness),  the 
rumbling  noises  prodiiced  by  muscular 
contractions  in  the  chest  wall  may  simu- 
late rales  so  closely  that  the  diagnosis  of 
bronchitis  may  be  strongly  suggested. 
The  differentiation  between  rales  and 
muscle  sounds  has  already  been  discussed 
(see  above,  p.  87). 

(5)  Atelectatic  crepitation.  Crackling 
rales  heard  over  the  thin  margins  of  the 
lungs  at  the  base  of  the  axilla  or  along 
the  edges  of  the  manubrium  are  often  due 

to  atelectasis  (see  above).  From  bronchitis  they  are  distinguished 
by  their  situation  and  by  the  lack  of  symptoms.  They  are  best 
heard  at  the  point  shown  in  Fig.  124. 


Fig.  124.— The  Dots  are  Placed 
over  the  Area  where  Atelecta- 
tic Crepitation  Is  Oftenest 
Heard. 


Chronie  Bronchitis. 

So  far  as  the  bronchitis  itself  is  concerned,  there  may  be  no 
difference  in  the  physical  signs  between  the  acute  and  chronic  forms 


BRONCHITIS,  PNEUMONIA,   TUBERCULOSIS.  237 

of  the  disease ;  but  in  the  latter  one  almost  invariably  finds  asso- 
ciated with  the  bronchitis  itself  a  considerable  degree  of  eniiDhy- 
sema,  of  asthma,  or  of  both  conditions.  Indeed,  the  foreground  of 
the  clinical  picture  and  the  bulk  of  the  physical  sign  are  made  up 
by  the  emphysema  and  asthma,  rather  than  by  the  bronchitis  itself. 
Accordingly,  I  shall  not  discuss  chronic  bronchitis  any  further  at 
this  point,  but  will  return  to  the  subject  in  the  chapter  on  Emphy- 
sema. 

CKOUPOUS  PNEUMONIA. 

In  its  typical  form  croupous  or  fibrinous  pneumonia  produces 
solidification  of  one  or  more  lobes,  usually  the  lower,  the  process 
being  accurately  bounded  by  the  interlobular  fissures.  Although 
the  physical  signs  of  the  earlier  stages  differ  considerably  from 
those  of  the  later  ones,  there  seems  to  be  no  siTfiicient  ground  for 
marking  off  stages  of  engorgement  and  of  red  and  gray  hepatiza- 
tion, for  clinically/  these  stages  cannot  be  distinguished. 

The  solidification  may  begm  in  the  deeper  parts  of  the  lung 
('^central  pneumo7iia"),  so  that  no  physical  signs  are  obtainable 
until  later  in  the  course  of  the  disease,  when  the  process  extends 
to  the  surface  of  the  lung. 

Massive  pneumonia ,  in  which  the  bronchi  as  well  as  the  air  cells 
are  plugged  with  fibrm  and  leucocytes,  is  a  relatively  rare  form  of 
the  disease,  but  possesses  great  clinical  importance  on  account  of  the 
marked  resemblance  between  its  physical  signs  and  those  of  pleural 
effusion. 

The  frequency  of  endocarditis  and  pericarditis  in  connection 
with  lobar  pneumonia,  especially  with  those  of  the  left  side,  should 
be  borne  in  mind. 

Physical  Signs. 

{a)  Inspection.— T\ve  aspect  of  the  patient  frequently  suggests 

the  diagnosis;  the  face  is  anxious,  often  flushed  or  slightly  cya- 

nosed,  the  flush  sometimes  affecting  most  strikingly  the  side  of  the 

face  corresponding  to  the  lung  affected.'     Herpetic  vesicles  ("cold 

1  Perhaps  because  the  patient  is  apt  to  lie  upon  the  affected  side. 


238    FHYSICAI   DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

sores  ")  are  often  to  be  seen  around  the  moutli  or  nose.  The  rapid, 
difficult  breathing  is  at  once  noticable,  and  expiration  is  often  ac- 
companied by  a  grunt.  The  use  of  the  accessory  muscles  of  respi- 
ration and  the  dilatation  of  the  nostrils  attract  attention. 

The  eombmation  of  marked  dysjinoea  with  absence  of  dropsy  is 
met  with  more  frequently  in  pneumonia  than  in  any  other  disease. 
Both  sides  of  the  chest  usually  move  alike,  but  occasionally  the 
affected  side  shoAvs  deficient  expansion  especially  in  the  later  stages 
of  the  disease,  and  the  other  side  of  the  chest  shows  increased  re- 
spiratory movements  (compensatory).  Rarely  the  pulsations  of  the 
heart  may  be  transmitted  to  the  chest  wall  through  the  affected  lung. 

When  pneumonia  attacks  a  feeble  old  man,  or  follows  injuries 
(surgical  pneumonia),  its  onset  may  be  insidious,  and  none  of  the 
phenomena  just  described  may  be  seen. 

(i)  Palpation. — In  the  great  viajority  of  eases  tactile  fremitus  is 
markedly  increased  over  the  affected  aren,^  but  in  case  the  bronchi 
are  occluded  by  secretions  or  fibrinous  exudate,  fremitus  may  be  di- 
minished or  altogether  absent.  A  few  hard  coughs  will  sometimes 
clear  out  the  tubes  and  thus  materially  assist  the  diagnosis.  Occa- 
sionally an  increase  in  superficial  temperature  of  the  affected  side 
may  be  noticed  by  palpation,  and  rarely  one  feels  a  friction  rub 
due  to  the  fibrinous  pleurisy  which  almost  invariably  accompanies 
the  disease. 

(c)  Percussion. — Over  the  area  affected  thej^ercussion  note  is  gener- 
ally  dull  and  viay  he  almost  flat,  except  in  the  earliest  and  latest 
stages  of  the  disease,  in  which  it  may  have  a  tympanitic  quality  with 
or  without  an  element  of  slight  dulness.  More  marked  tympany  is 
usually  present  over  the  unaffected  lobes  of  the  diseased  lung  (that 
is,  over  the  upper  lobes  in  the  great  majority  of  cases.) 

The  conditions  just  described  represent  the  great  majority  of 
cases,  but  the  following  exceptions  occur : 

(1)  In  the  pneumonias  of  children,  and  occasionally  in  adults, 
dulness  may  be  absent. 

'  By  u.sing  the  edge  instead  of  the  flat  of  the  hand  the  boundaries  of  sol- 
idified lobes  may  often  be  very  accurately  marked  out  by  means  of  the  tactile 
fremitus. 


BRONCHITIS,  PNEUMONIA,   TUBERCULOSIS.  239 

(2)  When  the  lower  lobe  of  the  left  lung  is  affected,  a  distinctly 
tympanitic  quality  may  be  transmitted  to  the  consolidated  area 
from  a  distended  stomach  or  colon. 

(3)  In  rare  cases,  the  percussion  over  the  consolidated  area  may 
be  of  a  metallic  quality,  or  produce  the  "  cracked-pot "  sound. 

(4)  In  central  pneumonia  there  may  be  no  change  in  the  percus- 
sion note,  or  it  may  be  unusually  full  and  deep  so  that  the  sound 
side  seems  dull  by  comparison. 

A  solidified  lobe  increases  so  much  in  size  that  the  area  of  dul-. 
ness  corresponding  to  it  often  seems  incredibly  large.     Thus,  al- 
though the  lower  lobe  reaches  in  health  not  more  than  half-way  up 
the  scapula,  when  solidified  it  produces  dulness  throughout  nearly 
the  whole  back. 

The  right  base  is  the  most  frequent  seat  of  pneumonic  solidifica- 
tions,  but  the  dulness  corresponding  to  it  is  often  first  noticeable  in 
the  posterior  axillary  line.  A  dulness  appreciable  only  in  the  front 
of  the  chest  is  almost  sure  to  correspond  to  the  vipper  lobe,  while 
signs  in  the  lower  part  of  the  right  axilla  correspond  to  the  middle 
lobe.  Many  cases  of  central  pneumonia  first  appear  at  the  surface 
in  one  or  the  other  axilla. 

As  regards  the  amount  of  solidification  needed  to  produce  per- 
cussion dulness,  Wintrich  says  that  the  minimum  is  a  patch  5  cm. 
in  diameter,  2  cm.  deep,  and  superficially  situated. 

Percussion  often  makes  us  aware  of  an  increased  resistance  or 
diminished  elasticity  of  the  affected  side,  although  the  resistance  is 
seldom  as  marked  as  in  large  pleural  effusions. 

(d)  Auscultation. — In  the  great  majority  of  cases  typical  tubular 
breathing  is  to  be  heard  over  the  affected  area.  Since  a  whisi)er 
is  practically  a  forced  expiration,  this  tubidar  quality  is  very  well 
brought  out  if  the  patient  is  made  to  whisper  "one,  two,  three," 
or  any  other  succession  of  syllables,  and  by  this  method  the  fatigue 
and  pain  of  deep  breathing  may  be  saved.  By  this  use  of  the 
whispered  voice  one  may  accurately  mark  out  the  boundaries  of  the 
consolidated  area,  and  demonstrate  in  many  cases  that  it  coincides 
with  the  boundaries  of  one  lobe  of  the  lung. 

In  the  earliest  stages  of  the  disease  the  breathing  may  be  bron- 


240    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

cho- vesicular ;  more  often  it  is  feeble  or  suppressed  over  the  con- 
solidated area,  and  ''crepitant  rales,"  that  is,  very  line  crackling 
sounds,  may  be  heard  at  the  end  of  mspiration,  but  these  are  much 
more  common  in  the  stage  of  resolution'  ("crepitans  redux  "). 

If  some  of  the  smaller  bronchi  are  blocked,  as  is  not  infre- 
quently the  case,  respiration  is  absent  or  very  feeble,  and  such 
cases  are  often  mistaken  for  pleuritic  eifusion.  Li  pneumonia  of 
the  upper  lobe  it  is  not  rare  for  bronchial  breathing  to  be  absent 
even  Avithout  plugging  of  the  bronchi. 

In  cases  of  "central  pneumonia,"  that  is,  when  the  area  of 
solidification  is  in  the  interior  of  the  organ,  there  may  be  no 
change  in  the  breath  sounds,  or  a  bronchial  element  may  be  faintly 
audible  on  auscultation  with  the  unaided  ear,  and  only  by  this 
method. 

The  intensity  of  the  spoken  or  whispered  voice  is  greatly  in- 
creased over  the  area  of  consolidation,  and  sometimes  the  Avords 
can  be  distinguished.  The  nasal  twang  known  as  '*  eyopliomj  "  is 
occasionally  to  be  heard.  In  the  majority  of  cases,  as  has  been 
already  stated,  the  right  lower  lobe  posteriorly  is  affected,  so  that 
the  consolidated  area  is  immediately  in  apposition  with  the  spmal 
column.  Under  these  circumstances,  it  is  not  v.[,  all  uncommon  to 
hear  bronchial  breathing  transmitted  from  the  consolidated  lobe 
to  a  narrow  zone  close  along  the  spinal  column  on  the  sound  side. 
Such  a  zone  is  often  mistaken  for  consolidation  (see  Fig.  125). 

The  signs  are  usually  less  marked  in  the  axilla  and  in  the  front 
of  the  lung,  but  in  a  minority  of  cases,  and  especially  Avhen  the 
upper  lobes  are  affected,  the  signs  are  wholly  in  the  front.  When 
searching  for  evidences  of  consolidation  in  persons  suspected  to 
have  pneumonia,  one  should  never  omit  to  examine  the  apices  and 
very  summit  of  the  armpit,  pressing  the  stethoscope  up  behind  the 
anterior  fold  of  the  axilla. 

In  examining  the  posterior  lobes,  Avhen  the  patient  is  too  Aveak 
to  sit  up  and  is  loath  CA^en  to  turn  upon  the  side,  the  BoAvles  steth-  ' 

'  Crepitant  rSiles  are  rarely  heard  in  the  pneumonias  of  infancy  and  old 
age.  They  are  not  peculiar  to  pneumonia,  but  occur  in  pulmonary  cedema  or 
hemorrhagic  infarction— conditions  easily  distinguished  from  pneumonia. 


BROXCHJTIS,  PXEUJ^OXJA,  TUBERCULOSIS. 


241 


oscope  is  a  great  convenience,  owing  to  the  ease  with  which  its  flat- 
tened extremity  may  be  worked  in  between  the  patient  and  the  bed- 
clothes without  eaosing  any  discomfort. 

^Vhen  resolution  begins,  the  signs  may  suddenly  and  completely 
disappear  within  a  few  hours.  More  frequently  the  bronchial 
breathing  is  modified  to  broncho- vesicular,  dulness  and  broncho- 
phony become  less  marked,  fine  crackling  rales  (crepitans  redux) 
or  coarser  moist  bubbles  appear,  and  the  lung  gradually  returns  to 
its  normal  condition  within  a  period  of  three  or  four  days.     In  the 


Brondiial  breathing 
transmitted  by  _ 
spimil  column  to 
aoond  kmg. 


^^^  Trmpany. 


Fig.  lS.-I>iagram  c^  Sijnia 


active  stages  of  the  disease  the  entire  absence  of  rales  is  very  char- 
acteristic. In  about  19  per  cent,  of  the  cases  the  solidification  of 
the  lung  persists  after  the  fall  of  the  temperature ;  indeed,  it  may 
be  weeks  or  even  months  before  it  clears  up,  and  yet  the  lung  may 
be  perfectly  sound  in  the  end.  On  the  other  hand,  abscess  or  gan- 
grene may  develop  in  the  solidified  lobe,  or  the  latter  may  be  trans- 
formed into  a  mass  of  tough  fibrous  tissue,  and  the  adjacent  portion 
of  the  chest  may  fall  in  (cirrhosis  of  the  limg,  chronic  interstitial 
pneumonia). 

"  Wandering  pneumonia  "  is  a  term  applied  to  cases  in  which 
16 


242     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

the  consolidation  disappears  in  one  lobe  only  to  reappear  in  another; 
or  spreads  gradually  from  lobe  to  lobe.  The  physical  signs  in  such 
cases  do  not  differ  essentially  from  those  already  described. 

Sum  mar//. 

In  a  typical  case  one  finds  (oftenest  at  the  right  base  behind) 

1.  Dulness  on  percussion. 

2.  Increased  tactile  fremitus  and  voice  sounds. 

3.  Tubular  breathing  and  occasionally  crepitant  rales. 

These  signs  occurring  in  connection  with  fever,  cough,  rusty 
sputa,  pam  in  the  side,  dyspnoea,  and  herpes,  are  sufficient  for  the 
diagnosis. 

But  many  cases — some  say  the  majority — are  not  typical  when 
first  seen.     The  following  are  the  commonest  anomalies : 

(a)  There  may  be  tympany  instead  of  dulness,  especially  in 
children  or  when  the  solidification  is  at  the  left  base. 

(b)  The  breathing  may  be  feehle  but  vesicular  in  character,  or 
it  may  be  absent,  in  case  bronchi  are  plugged ;  from  the  same  cause 

((')  Tactile  fremitus  may  be  diminished. 

A  hard  cough  may  clear  out  the  bronchi  and  produce  a  sudden 
metamorphosis  of  the  physical  signs  with  a  return  to  the  normal 
type. 

In  these  atypical  cases,  we  have  to  fall  back  upon  the  symp- 
toms, the  history,  the  blood,  and  sputa  for  help  in  the  diagnosis. 

Deep-seated  pneumonic  processes  may  appear  at  the  surface  in 
out-of-the-way  places,  e.g.,  at  the  summit  of  the  axilla,  and  the 
area  of  demonstrable  physical  signs  may  be  no  larger  than  a  silver 
dollar.  A  thorough  examination  of  every  inch  of  the  chest  is 
therefore  essential  in  doubtful  cases. 

In  the  later  stages  of  the  disease  crepitant  or  other  fine  rales 
often  appear,  and  the  signs  of  solidification  suddenly  or  gradually 
disappear. 

JHfferenthil  Diar/nosis. 

Pneumonic  solidification  is  to  be  distinguished  from 

(1)  Pleuritic  effusion. 

(2)  Tuberculosis  of  the  lung. 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS.  243 

(1)  From  pleuritic  effusion,  pneumonia  is  to  be  distinguished 
in  the  great  majority  of  cases  by  differences  in  the  onset,  course, 
and  general  symptoms  of  the  disease.  In  pneumonia  the  patient  is 
far  more  suddenly  and  violently  attacked,  the  dyspnoea  is  much 
greater,  cough  and  pain  are  more  distressing  and  more  frequent, 
the  temperature  is  higher,  and  the  sputum  often  characteristic.  In 
pleuritic  effusion  the  dulness  is  Usually  more  intense  than  in  pneu- 
monia. Tactile  fremitus  and  voice  sounds  are  increased  in  pneu- 
monia (except  when  the  bronchi  are  plugged) ;  decreased  or  absent 
in  pleuritic  effusion.  Bronchial  breathing  may  be  heard  in  both 
diseases,  but  is  usually  feeble  and  distant  when  occurring  in  pleu- 
risy, and  loud  in  pneumonia.  If  the  affection  be  on  the  left  side, 
the  diagnosis  is  much  aided  by  the  presence  of  dislocation  of  the 
heart,  which  is  produced  l)y  pleuritic  effusion  and  never  by  pneu- 
monia. In  cases  of  pneumonia  with  occluded  bronchi,  one  may 
have  every  sign  of  pleuritic  effusion — flatness,  absent  breathing, 
voice  and  fremitus — and  in  such  cases  the  absence  of  any  disloca- 
tion of  the  heart,  provided  the  disease  is  upon  the  left  side,  is  very 
important.  If  a  similar  condition  of  things  occurs  upon  the  right 
side,  one  may  have  to  fall  back  upon  the  symptoms  and  upon  such 
evidence  as  the  blood  count,  herpes,  sputum,  etc. 

(2)  Tuberculosis  of  the  lung  causing,  as  it  may,  a  diffuse  sol- 
idification of  the  organ,  may  be  indistinguishable  from  pneumonia 
if  we  take  account  only  of  the  physical  signs,  but  the  two  diseases 
can  usually  be  distinguished  without  difficulty  by  the  diiference  in 
their  symptoms  and  course,  and  by  the  presence  or  absence  of  tuber- 
cle bacilli  in  the  sputum. 

Inhalatiox  Pxeumoxia.     Aspiration  Pneumoxia. 

When  food  or  other  foreign  substances  are  drawn  into  the  air 
passages,  as  may  occur,  for  example,  during  recovery  from  ether 
narcosis,  a  form  of  broncho-pneumonia  may  be  set  up,  in  which  the 
solidified  patches  are  not  infrequently  large  enough  to  be  recognized 
by  the  ordinary  methods  of  physical  examination. 

The  lesions  are  usually  hilateml  and  accompanied  by  a  general 
bronchitis.     Slight  dulness  and  indistinct  bronchial  breathuig  can 


244    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

usually  be  made  out  over  an  irregular  area  in  the  backs  of  both 
lungs. 

The  signs  are  considerably  less  marked  than  in  croupous  pneu- 
monia, and  the  boundai-ies  of  the  irregular  patches  of  disease  do 
not  correspond  to  those  of  a  lobe  of  the  lung. 

If  not  rapidly  fatal,  the  disease  may  be  complicated  by  i)ulmo- 
nary  gangrene  or  abscess  and  large  quantities  of  fetid  pus  may  be 
spit  up. 

Bkoxcho-Pxeumoxia. 

(Catarrhal  or  Lobular  Pneumonia.) 

Multiple  small  areas  of  solidification  scattered  through  both 
lungs,  interspersed  with  areas  of  collapse,  and  usually  associated 
with  diffuse  bronchitis,  occur  very  frequently  m  children  producmg 
severe  dyspnoea,  cyanosis,  cough,  and  somnolence,  and  running  a 
very  fatal  course. 

The  solidified  lobules  may  fuse  so  as  to  form  considerable  areas 
of  hepatized  lung,  or  there  may  be  no  lesion  larger  than  a  pea. 

This  is  the  usual  type  of  "  lung  fever  "  in  infants,  although  or- 
dinaiy  lobar  pneumonia  is  not  rare  in  infancy  and  in  childhood. 

The  widespread  atelectasis  of  the  lower  lobes  Avhich  is  associated 
with  the  disease  in  most  cases  owing  to  the  plugging  of  the  bronchi 
with  tenacious  secretions,  is  probably  as  serious  in  its  effects  as  the 
pneumonic  foci  themselves. 

The  anterior  and  upper  parts  of  the  lungs  often  become  dis- 
tended with  air  (vicarious  emphysema)  and  render  the  physical 
signs  very  confusing  and  deceptive. 

Phl/sical  Signs. 

In  the  majority  of  cases  there  are  no  characteristic  physical 
signs,  and  the  diagnosis  has  to  be  made  largely  from  the  symptoms 
and  course  of  the  disease.  The  consolidated  areas  are  usually  too 
small  to  give  rise  to  any  dulness  on  percussion,  or  to  any  change  in 
the  breath  sounds,  voice  sounds,  or  fremitus,  so  that  auscultation 
shows,  as  a  rule,  nothing  more  than  patches  of  fine  rales  occurring 
at  the  end  of  expiration.     Localized  tympanitic  resonance  is  some- 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS.  245 

times  present  over  the  diseased  area,  making  the  sounder  portions 
of  the  lungs  seem  dull  by  comparison.  Occasionally,  when  many 
lobules  have  fused  into  a  single  mass  of  larger  area,  the  ordinary 
'signs  of  consolidation  may  be  obtained,  although  they  are  apt  to 
disappear  within  twenty-four  or  forty-eight  hours  and  appear  in 
another  situation.  As  above  said,  the  diagnosis  is  usually  to  be 
made,  if  at  all,  from  the  combination  of  the  physical  signs  of  a 
localized  bronchitis  with,  the  symptoms  of  pneumonia.  "This  pa- 
tient," we  say,  "has  only  the  signs  of  bronchitis,  but  he  is  too 
si(;k.  The  cyanosis,  dyspnoea,  and  fever  are  too  marked.  He  is 
sicker  than  simple  bronchitis  will  account  for." 

Differential  Diagnosis. 

(a)  Acute  i^iilnionary  tuberculosis  may  be  indistinguishable  from 
broncho-pneumonia  by  the  physical  signs  alone.  The  diagnosis 
must  be  made  from  the  history  and  course  of  the  disease  or  from 
the  presence  of  tubercle  bacilli  in  the  sputa. 

{b)  The  extensive  atelectasis  of  the  lower  lobes  which  may  ac- 
company broncho-pneumonia  gives  rise  to  dulness  and  absence  of 
respiratory  and  vocal  sounds.  Thus,  the  signs  oi  pleuritic  effusion 
are  simulated,  and  in  children  the  possibility  of  empyema  should 
not  be  forgotten.  As  a  rule,  broncho-pneumonia  gives  rise  to  much 
greater  dyspnoea,  and  is  associated  with  a  more  extensive  bronchitis, 
than  usually  coexist  with  pleural  effusion.  The  atelectatic  lobules 
may  be  expanded  by  coughing  or  by  the  cutaneous  stimulus  of  cold 
water,  and  thus  resonance  and  breath  sounds  may  suddenly  return. 
With  pleuritic  effusions,  of  course,  such  a  change  is  impossible. 

TUBEECULOSIS  OF  THE  LUNGS. 

(1)  Incijnent  Tuberculosis. 

In  the  earlier  stages  of  the  disease  there  may  be  absolutely  no 
recognizable  physical  signs,  and  the  diagnosis  may  be  established 
only  by  the  positive  residt  of  a  tuberculin  injection  or  by  the  com- 
bination of  debility  with  slight  fever  not  otherAvise  to  be  accounted 
for. 


246    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

In  some  cases  the  earliest  evidence  of  the  disease  is  hmmoptysis. ' 
When  a  patient  consults  a  physician  on  account  of  haemoptysis,  it 
is  frequently  impossible  to  find  any  physical  signs  of  disease  in  the 
lungs ;  not  until  weeks  or  months  later  do  the  characteristic  changes 
recognizable  by  physical  examination  make  their  appearance. 

The  very  early  hoarseness  of  the  voice  in  tuberculous  patients  is 
of  great  importance  and  often  attracts  our  attention  to  the  lungs 
when  the  patient  has  said  nothing  about  them.  Definite  physical 
signs  in  the  lungs  and  tubercle  bacilli  in  the  spvita  (artificially  ob- 


Rales.  ^ 


Fig.  126.— Diagram  to  Show  Position  of  Earliest  Signs  in  Tuberculosis. 


tained  through  the  use  of  potassic  iodide,  see  beloAv)  may  occasion- 
ally be  demonstrated  before  any  cough  has  appeared.  On  the  other 
hand,  the  patient  may  cough  for  weeks  before  anything  abnormal 
can  be  discovered  in  the  lungs.  Occasionally  tuberculosis  begins 
with  an  ordinarily  bilateral  bronchitis.  I  have  found  tubercle  ba- 
cilli in  four  such  cases.  More  often  the  earliest  physical  signs 
are: 

(a)  Fine  crackling  rales  at  the  apex  of  one  lung,  heard  only 

'  Never  percus.s  a  patient  within  forty-eight  hours  after  a  hemorrhage,  and 
never  encourage  cough  or  forced  respiration  in  such  a  one.  There  is  danger 
of  starting  a  fresh  hemorrhage. 


BRONCHITIS,  PNEVMOyiA,  TUBERCULOSIS.  247 

with  or  after  cough  and  at  the  end  of  mspiration.  [Move  rarely 
squeaks  may  be  heard.]     (See  Fig.  126). 

(0)  A  slight  diminution  in  the  excursion  of  the  diaphragm  on 
the  alfected  side,  as  shown  by  Litten's  diaphragm  shadow. 

(c)  Slight  diminution  in  the  intensity  of  the  respiratory  mur- 
mur, with  or  without  interrupted  uispiration  (^' cofj-ic/wel  l/reath- 
imj  "). 

(it)  In  examining  the  apices  of  the  lungs  for  evidence  of  early 
tuberculosis  one  should  secure  if  possible  perfect  quiet  m  the  room, 
and  have  the  clothes  entirely  removed  from  the  patient's  chest. 
The  ordinary  hard-rubber  chest-piece  is  better  than  the  chest-piece 
of  the  Bowles  instrument  when  we  Avish  to  search  the  apices  for 
fine  rales.  After  listening  during  quiet  breathing  over  the  apices 
above  and  below  the  clavicle  in  front,  and  above  the  spine  of 
the  scapula  behind,  the  patient  should  be  directed  to  breathe  out 
and  then,  at  the  end  of  expiration,  to  cough.  During  the  deep 
inspiration  which  is  likely  to  precede  or  to  follow  such  a  cough  one 
should  listen  as  carefully  as  possible  at  the  apex  of  the  lung,  above 
and  below  the  clavicle,  concentrating  attention  especially  upon  the 
last  quarter  of  the  inspiration,  when  rales  are  most  apt  to  appear. 
Sometimes  only  one  or  two  crackles  may  be  heard  with  each  inspi- 
ration, and  not  infrequently  they  will  not  be  heard  at  all  unless  the 
patient  is  made  to  cough,  but  even  «  sin yle  rale,  if  i^ersistent,'^  is 
important.  In  children  who  cannot  cough  at  will,  one  can  accom- 
plish nearly  the  same  result  by  making  them  count  as  long  as  pos- 
sible with  one  breath  and  then  listening,  to  the  immediately  suc- 
ceeding inspiration.  When  listening  over  the  apex  of  the  lung, 
one  should  never  allow  the  patient  to  turn  his  head  sharply  in  the 
other  direction,  since  such  an  attitude  stretches  the  skin  and  mus- 
cles on  the  side  on  which  Ave  are  listening  so  as  to  produce  annoy- 
ing muscle  sounds  or  skin  rubs. 

In  cases  m  which  one  suspects  that  incipient  tuberculosis  is 

'  Rales  heard  only  during  the  first  few  breaths  and  not  found  to  persist  on 
subsequent  examinations,  may  be  due  to  the  expansion  of  atelectatic  lobules 
(see  above,  p.  105  . 


248     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

present  and  yet  in  which  no  positive  evidence  can  be  found,  it  is  a 
good  plan  to  give  iodide  of  potassium  (gr.  vii.  three  times  a  day)  for 
a  few  days.  The  effect  of  this  drug  is  often  to  make  rales  more 
distinct,  and  sometimes  to  increase  expectoration  so  that  tubercle 
bacilli  can  be  demonstrated  when  before  none  were  to  be  obtamed. ' 

(0)  The  diminution  in  the  excursion  of  the  diaphragm  upon  the 
affected  side  in  cases  of  incipient  phthisis  has  been  much  insisted 
upon  by  F.  H.  Williams  and  others  who  have  interested  themselves 
in  the  radioscopy  of  the  chest.  Litten's  diaphragm  shadow  gives 
us  a  method  of  observing  the  same  phenomenon  Avithout  the  need 
of  a  fluoroscope.  Even  very  slight  tuberculous  changes  in  the  lung 
are  sufficient  to  diminish  its  elasticity  and  so  to  restrict  its  excur- 
sion and  that  of  the  diaphragm.  Comparisons  must  always  be 
made  with  the  sound  side  in  such  cases,  as  individuals  differ  very 
much  in  the  extent  with  which  they  are  capable  of  depressing  the 
diajjhragm.  It  must  be  remembered  that  pleuritic  adhesions,  due 
to  a  previous  inflammation  of  the  pleura,  may  diminish  or  alto- 
gether abolish  the  excursion  of  the  diaphragm  shadow,  independ- 
ently of  any  active  disease  in  the  lung  itself. 

Those  who  are  expert  in  the  use  of  the  fluoroscope  believe  that 
they  can  detect  the  presence  of  tuberculosis  in  the  lung  by  radi- 
oscopy at  a  period  at  which  no  other  method  of  physical  examina- 
tion shows  anything  abnormal.  I  shall  return  to  the  consideration 
of  this  point  in  the  section  on  Radioscopy." 

Interrupted  or  cog-wheel  respiration,  in  which  the  inspiration 
is  made  up  of  sharp,  jerky  puffs,  signifies  that  the  entrance  of  the 
air  into  the  alveoli  is  impeded,  and  such  impediment  is  most  likely 
to  be  due  to  tuberculosis  when  present  over  a  considerable  period 
in  a  localized  area  of  pulmonary  tissue. 

'  Any  irritating  vapor — for  example,  creosote  vapor — which  produces  vio- 
lent cough  and  expectoration,  may  be  used  to  expel  bronchial  secretions  in 
doubtful  cases.  Tubercle  bacilli  may  then  be  found  in  the  sputum  of  patients 
who,  without  the  irritating  inhalation,  have  no  cough  and  so  no  sputa. 

-  See  Appendix  C. 


BRONCHITIS,  PNEUMONIA.  TUBERCULOSIS. 


249 


(2)  Moderattily  Advanced  Cases 

So  far  I  have  been  speaking  of  the  detection  of  tuberculosis  at 
a  stage  prior  to  the  production  of  any  considerable  amount  of  solid- 
ification. The  sigiis  considered  have  been  those  of  bronchitis 
localized  at  the  apex  of  the  lung,  or  of  a  slightly  diminished  pul- 
monary elasticity,  whether  due  to  pleuritic  adhesions  or  to  other 
causes.  We  have  next  to  consider  the  signs  in  cases  in  which  so- 
lidification is  present,  though  relatively  slight  in  amount  This 
condition  is  comparatively  easy  to  recognize  when  it  occurs  at  the 


Raies.-___ 


^-     Complete 
solidiUcation. 


Partial 
solidiUcation. 


4 — Rales. 


Fig.  127.— Diagram  of  Sijrns  in  Phthisis. 

left  apex,  but  more  diificult  in  case  only  the  right  apex  is  diseased 
Partial  solidification  of  a  small  area  of  lung  tissue  at  the  left  apex 
gives  rise  to 

{a)  Slight  dulness  on  light  percussion,*  with  increased  resist- 
ance. 

(i)  Slight  increase  in  the  intensity  of  the  spoken  and  whispered 
voice,  and  of  the  tactile  fremitus  (in  many  cases) 

1  Other  causes  of  dulness,  such  as  asymmetry  of  the  chest,  pleural  thicken- 
ing, and  tumors,  must  be  excluded.  Emphysema  of  the  lobules  surrounding 
the  tuberculous  patch  may  completely  mask  the  dulness. 


250     PHYSICAL   DIAGNOSIS  OF  DISEASES   OF  THE  CHEST 

(f)  Some  one  of  the  numerous  varieties  of  broncho-vesicular 
breathing  (true  bronchial  breathing  is  a  late  sign). 

(d)  Abnormally  loud  transmission  of  the  heart  sounds,  espe- 
cially under  the  clavicle. 

(e)  Cardio-respiratory  murmurs  (ride  ji.  139)  are  occasionally 
due  to  the  pressure  of  a  tuberculous  lobule  u^jon  the  subclavian 
artery.  In  connection  with  other  signs  they  are  not  altogether 
valueless  in  diagnosis 

In  case  there  is  also  a  certain  amount  of  secretion  in  the  bron- 
chi of  the  affected  area  or  ulceration  around  them,  one  often  hears 
rales  of  a  peculiar  quality  to  which  Skoda  has  given  the  name  of 
^^ cousouatlnf/ vales."  Rales  produced  in  or  very  near  a  solidified 
area  are  apt  to  have  a  very  sharj),  crackling  quality,  their  intensity 
being  increased  by  the  same  acoustical  conditions  which  increase 
the  intensity  of  the  voice  sounds  over  the  same  area.  AVhen  such 
rales  are  present  at  the  apex  of  either  lung,  the  diagnosis  of  tuber- 
culosis is  almost  certain,  but  if,  as  not  infrequently  occurs,  there 
are  no  rales  to  be  heard  over  the  suspected  area,  our  diagnosis  is 
clear  ojily  in  case  the  signs  occur  at  the  left  apex  Precisely  the 
same  signs,  if  present  at  the  right  apex,  leave  us  in  doubt  regard- 
ing the  diagnosis,  for  the  reason  that,  as  has  been  explained  above, 
we  find  at  the  apex  of  the  right  lung  in  health  signs  almost  exactly 
identical  with  those  of  a  slight  degree  of  solidification.  Hence,  if 
these  signs,  and  only  these,  are  discovered  at  the  right  apex,  we 
cannot  feel  sure  about  the  diagiiosis  until  it  is  confirmed  by  the 
appearance  of  rales  in  the  same  area  of  the  left  side  (whether  under 
the  influence  of  iodide  of  potassium  or  spontaneously),  or  by  the  find- 
ing of  tubercle  bacilli  in  the  sputum.' 

A  sign  characteristic  of  early  tuberculous  changes  in  the  lung  and 
one  which  I  have  frequently  observed  in  the  lower  and  relatively 
sounder  lobes  of  tuberculous  lungs  is  a  raising  of  the  pitch  of  inspi- 
ration, without  any  other  change  in  the  quality  of  the  breathing  or 
any  other  physical  signs      The  importance  of  this  sign  in  the  diag- 

'  The  natural  disparity  between  tlie  two  apices  is  less  marked  in  the  supra- 
spinous fossa  behind  than  over  the  clavicle  in  front,  and  hence  pathological 
dulness  at  the  apex  is  more  ofteii  demonstrable  behind  than  in  front. 


BRONCHITIS,  PNEUMOmA,   TUBERCULOSIS.  251 

nosis  of  early  tuberculosis  of  the  lungs  was  insisted  upon  by  the 
elder  Flint  in  his  work  on  "The  Respiratory  Organs"  (1800),  and 
has  more  recently  been  mentioned  by  Norman  Bridge. 

It  must  never  be  forgotten  that  tuberculosis  may  take  root  in 


Fig.  128. 


-This  Patient  has  Solididcation  at  both  Apices  and  Tubercle  Bacilli  in  the  Sputa.    He 
feels  perfectly  well. 


the  most  finely  formed  chests  and  in  persons  apparently  in  blooming 
health.  The  "phthisical  chest  "  and  the  sallow,  emaciated  figure  of 
the  classical  descriptions  apply  only  to  very  advanced  cases.  Fig. 
128  represents  a  patient  with  moderately  advanced  signs  of  jihthisis 
and   abundant  tubercle   bacilli  in  the  sputa.     He  feels  perfectly 


252     PHYSICAL  DIAGXOSIS  OF  DISEASES  OF  THE  CHEST. 

well  and  is  at  Avoik.     On  the  other  hand,  a  patient  with  very  slight 
signs  may  be  utterly  prostrated  by  the  toxaemia  of  the  disease. 

(3)  Advanced  Phthisis. 

Characteristic  of  the  more  advanced  stages  of  tuberculosis  in  the 
lungs  is  the  existence  of  large  areas  of  solidified  and  retracted  lung, 
and,  to  a  lesser  extent,  the  signs  of  cavity  formation.  The  patients 
are  pale,  emaciated,  and  feverish.  The  signs  of  solidification  have 
already  been  enumerated  in  speaking  of  pneumonia.     They  are : 

1.  Marked  dulness,  or  even  flatness,'  with  increased  sense  of  re- 
sistance. 

2.  Great  increase  of  voice  sounds  or  of  tactile  fremitus. 

3.  Tubular  breathing,  sometimes  loud,  sometimes  feeble. 

4.  As  a  rule,  coarse  rales,  due  to  breaking  down  of  the  caseous 
tissue,  are  also  to  be  heard  over  the  solidified  areas.  Sometimes 
these  rales  are  produced  within  the  pleuritic  adhesions,  which  are 
almost  invariably  present  in  such  cases.  If  they  disappear  just 
after  profuse  expectoration,  one  may  infer  that  they  are  produced 
within  the  lung. 

Increase  in  the  intensity  of  the  spoken  voice,  of  the  whispered 
voice,  or  of  the  tactile  fremitus  may  be  marked  and  yet  no  tubular 
breathing  be  audible.  Each  of  these  signs  may  exist  and  be  of  im- 
portance as  signs  of  solidification  without  the  others.  As  a  rule, 
it  is  true,  they  are  associated  and  form  a  very  characteristic  group, 
but  there  are  many  exceptions  to  this  rule. 

The  tendency  of  the  spinal  coliunn  to  transmit  to  the  sound 
lung  sounds  produced  in  an  area  of  solidification  immediately 
adjacent  to  it  on  the  other  side,  has  been  already  alluded  to  in 
the  section  on  pneumonia,  and  what  was  then  said  holds  good  of  tu- 
berculous solidification.  Owing  to  this  it  is  easy  to  be  misled  into 
diagnosing  solidification  at  both  apices  when  only  one  is  affected. 

Since  solidification  is  usually  accompanied  by  retraction  in  the 
affected  lung  in  very  advanced  cases,  the  chest  falls  in  to  a  gi-eater 

'  Unless  senile  emphysema  masks  it.  Fibroid  phthisis  (vide  infra)  may 
show  no  duhiess.  Remember  that  gastric  tympany  may  be  transmitted  to  the 
left  lung  and  mask  dulness  there. 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS. 


253 


or  less  extent  over  the  affected  area,  and  the  respiratory  excursion 
is  much  diminished,  as  shown  by  ordinary  inspection  and  by  the 
diminution  or  disappearance  of  the  excursion  of  the  diaphragm 
shadow.  The  intensity  of  the  tubular  breathing  depends  on  the 
proximity  of  the  solidified  portions  to  the  chest  wall  and  to  the 
large  bronchi,  as  well  as  on  the  presence  or  absence  of  pleuritic 
thickening. 

It  is  rare  to  find  a  whole  lung  solidified.     The  process,  begin- 
ning at  the  apex  or  just  below,  extendi  down  as  far  as  the  fourth 


Bronchial  breath- 
ing, dulness.  '••»^ 

Increased  fremitus. 


Increased  voice 
sounds. 


'  Rales. 


Rales 


■To  niustrate  Projfress  of  Signs  in  Pulrmnary  Tuberculosis. 


rib  in  front,  i.e.,  through  the  upjjer  lobe,  in  a  relatively  short  time, 
but  below  that  point  its  progress  is  comparatively  slow  and  the 
lower  lobes  may  be  but  little  affected  up  to  the  time  of  death.  On 
the  relatively  sound  side  the  exaggerated  (compensatory)  resonance 
may  mask  the  dulness  of  a  beginning  solidification  there,  which 
sooner  or  later  is  almost  sure  to  occur.  It  is  exceedingly  rare  for 
the  disease  to  extend  far  in  one  lung  without  involving  the  other. 

About  the  time  that  the  tuberculous  process  invades  the  previ- 
ously sound  lung  it  is  apt  to  show  itself  at  the  apex  of  the  lower  lobe 


254     PHYSICAL  DIAGNOSIS   OF  DISEASES   OF  THE  CHEST. 

of  the  lung  first  affected.  Consonating  rales  appear  posteriorly  along 
the  line  which  the  vertebral  border  of  the  scapula  makes  when  the 
arm  is  raised  over  the  shoulder.  These  points  are  illustrated  in 
Fig.  129. 

Cavity  Formation. 

Cavities  of  greater  or  lesser  extent  are  formed  in  almost  every 
case  of  advanced  phthisis,  but  very  seldom  do  they  attain  such  size 
as  to  be  recognizable  during  life.  Indeed,  the  diagnosis  of  cavity 
in  phthisis  plays  a  much  larger  part  in  the  text-books  than  it  does 
in  the  practice  of  medicine,  smce  to  be  recognizable  by  physical 
examination  a  cavity  must  not  only  be  of  considerable  size  but  its 
walls  must  be  rigid  and  not  subject  to  collapse,'  it  must  communi- 
cate directly  Avith  the  bronchus  and  be  situated  near  the  surface  of 
the  lung,  and  it  must  not  be  filled  up  with  secretions.  It  can  read- 
ily be  appreciated  that  it  is  but  seldom  that  all  these  conditions  are 
present  at  once ;  even  then  the  diagnosis  of  cavity  is  a  difficult  one, 
and  I  have  often  known  skilled  observers  to  be  mistaken  on  this 
point. 

The  signs  upon  which  most  reliance  is  usually  placed  are : 

(ff)  Amphoric  or  cavernous  breathing. 

(b)  "Cracked-pot  resonance  "  on  percussion. 

(c)  Coarse,  gui-gling  rales. 

(a)  Cavernous  or  Amphoric  Itespiration. — "\Mien  present,  this 
type  of  breathing  is  almost  pathognomonic  of  a  cavity.  It  is  also 
to  be  heard  in  pneumothorax,  but  the  latter  disease  can  usually 
be  distinguished  by  the  associated  physical  signs.  Cavernous 
breathing  differs  from  bronchial  or  tubular  breathing  in  that  its 
pitch  is  lower  and  its  quality  ho/low.  The  pitch  of  expiration 
is  even  lower  than  that  of  inspiration.  Since  a  pulmonary  cavity 
is  almost  always  surrounded  by  a  layer  of  solidified  lung  tissue,  we 
usually  hear  around  the  area  occupied  by  the  cavity  a  ring  of  bron- 
chial breathing  with  which  we  can  compare  the  quality  of  the  cav- 
ernous sounds. 

'  Yet  not  so  rigid  as  to  be  uiiinflueuced  by  the  entrance  and  exit  cf  air. 


BRONCHITIS,  PNEUMONIA,   TUBERCULOSIS.  255 

(b)  Pei'cussion  sometimes  enables  us  to  demonstrate  a  circum- 
scribed area  of  tympanitic  resonance  sun-ounded  by  marked  dul- 
ness.  More  often  the  "  cracked-jDot  "  resonance  can  be  elicited  by 
percussing  over  the  suspected  area  while  the  chest-piece  of  the 
stethoscope  is  held  close  to  the  patient's  open  mouth. 

Cracked-pot  resonance  is  often  absent  over  cavities ;  rarely  oc- 
curs in  any  other  condition  (f'.y.,  in  percussing  the  chest  of  a 
healthy,  crying  baby,  and  occasionally  over  solidified  lung). 

{c)  The  voice  sounds  sometimes  have  a  peculiar  hollow  quality 
(amphoric  voice  and  whisper). 

{d)  Cough  or  the  movements  of  respiration  may  bring  out  over 
the  suspected  area  splashing  or  gurgling  sounds,  or  occasionally 
a  metallic  tinkle.  Flint  has  also  observed  a  circumscribed  bulging 
of  an  interspace  during  cough.  Bruce  noted  a  high-pitched  suck- 
ing sound  during  the  inspiration  following  a  hard  cough  ("  rubber- 
ball  sound"). 

Very  important  in  the  diagnosis  of  cavity  is  the  intermittence  of 
all  above-mentioned  signs,  which  are  present  only  when  the  cavity- 
is  comparatively  empty,  and  disappear  when  it  becomes  wholly  or 
mostly  filled  with  secretions.  For  this  reason,  the  signs  are  very 
apt  to  be  absent  in  the  early  morning  before  the  patient  has  expelled 
the  accumulated  secretions  by  coughing. 

Wintrich  noticed  that  the  note  obtained  when  percussing  over 
a  pulmonary  cavity  may  change  its  pitch  if  the  patient  opens  iiis 
mouth.  Gerhardt  observed  that  the  note  obtained  over  a  pulmo- 
nary cavity  changes  if  the  patient  shifts  from  an  upright  to  a  re- 
cumbent position.  Neither  of  these  points,  however,  is  of  much 
importance  in  diagnosis.  The  same  is  true  of  metamorphosing 
breathing  (see  above,  p.  98). 

Tuberculous  cavities  differ  from  those  produced  by  pulmonary 
abscess  or  gangrene  in  that  the  latter  are  usually  situated  in  the 
lower  two-thirds  of  the  lung.  Bronchiectasis,  an  exceedingly  rare 
condition,  cannot  be  distinguished  by  physical  signs  alone  from  a 
tuberculous  cavity. 


256    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

Fibroid  P /it  his  is. 

This  term  applies  to  slow  tuberculous  processes  Avith  relatively 
little  ulceration  and  much  fibrous  thickening. 

In  a  considerable  number  of  cases  the  physical  signs  do  not 
differ  materially  from  those  of  the  ordinary  ulcerating  forms  of 
the  disease,  but  occasionally  when  a  slow  chronic  process  at  the 
apex  of  the  lung  results  in  the  falling-away  of  the  parenchyma  of 
the  lung  so  that  we  have  left  a  cluster  of  bronchi  matted  together 
by  fibrous  tissue,  the  percussion  note  may  be  noticeably  tympani- 
tic; similar  tympany  may  be  due  to  emphysema  of  the  lobules 
surrounding  the  diseased  portion.  In  such  cases  rales  are  usu- 
ally entirely  absent ;  otherwise,  the  signs  do  not  differ  from  those 
of  ordinary  phthisis,  except  that  falling-in  of  the  chest  walls  over 
the  retracted  lung  may  be  more  marked.  Occasionally  the  heart 
maybe  drawn  toward  the  affected  lobes,  e.f/.,  upward  and  to  the 
right  in  right-sided  phthisis  at  the  apex.  In  two  cases  of  fibroid 
disease  at  the  left  base,  Flint  found  the  heart  beating  near  the 
lower  angle  of  the  left  scapula. 

Phthisis  with  Predominant  Pleural  Thickening. 

Tuberculosis  in  the  lung  is  in  certain  cases  overshadowed  by  the 
manifestations  of  the  same  disease  in  the  pleura,  so  that  the  signs 
are  chiefly  those  of  thickened  jdeur a.  To  this  subject  I  shall  return 
in  the  section  of  Diseases  on  the  Pleura  (see  below,  p.  271). 

Emphysematons  Form  of  Phthisis. 

Tubercle  bacilli  are  not  very  infrequently  found  in  the  sputa  of 
eases  in  which  the  history  and  physical  signs  point  to  chronic  bron- 
chitis with  emphysema.  I  have  seen  two  such  cases  within  a  year 
Dulness  is  wholly  masked  by  emphysema,  tubular  breathing  is 
absent,  and  piping  and  babbling  rales  are  scattered  throughout  both 
lungs.  The  emphysema  may  be  of  the  senile  or  small-lunged  type, 
as  in  one  of  my  recent  cases  (with  autopsy),  or  it  may  be  associ- 
ated with  huge  downy  lungs  and  the  "barrel  chest."     Such  cases 


BRONCHITIS,  PNEUMONIA,  TUBERCULOSIS.  257 

cannot  be  identified  as  phthisis  during  life  unless  we  make  it  an 
invariable  rule  to  examine  for  tubercle  bacilli  the  sputa  of  every 
case  in  which  sputa  can  be  obtained,  jio  matter  tvhat  are  the  i^hysi- 
cal  signs. 

Phthisis  with  Anomalous  DistHhution  of  the  Lesions, 

Very  rarely  a  tuberculous  process  may  begin  at  the  base  of  the 
lung  When  the  process  seems  to  begin  in  this  way,  a  healed  focus 
is  often  to  be  found  at  one  apex  surrounded  by  a  shell  of  healthy 
lung. 

The  summit  of  the  axilla  should  always  be  carefully  examined, 
as  tuberculous  foci  may  be  so  situated  as  to  produce  signs  only  at 
that  point. 

Another  point  often  overlooked  in  physical  examination  is  the 
linfjnla  ptdmonaHs  or  tongue-like  projection  from  the  anterior  mar- 
gin of  the  left  lung  overlapping  the  heart.  Tuberculosis  is  some- 
times found  further  advanced  at  this  point  than  anywhere  else. 

As  a  rule  cases  in  which  signs  like  those  of  phthisis  are  found 
at  the  base  of  the  lung  turn  out  to  be  either  empyema,  or  abscess, 
or  unresolved  pneumonia  (cirrhosis  of  the  lung). 

Acute  Pulmonary  Tuberculosis. 

No  one  of  the  three  forms  in  which  acute  phthisis  occurs,  viz., 

(a)  Acute  tuberculous  pneumonia, 

(b)  Acute  tuberculous  bronchitis  and  peribronchitis, 

(c)  Acute  miliary  tuberculosis,  involving  the  lungs,  can  be  rec- 
ognized by  physical  examination  of  the  chest.  The  first  form  is 
almost  invariably  mistaken  for  ordinary  croupous  pneumonia,  until 
the  examination  of  the  sputa  establishes  the  correct  diagnosis.  In 
the  other  two  forms  of  the  disease,  the  physical  signs  are  simpiy 
those  of  general  bronchitis. 

17 


CHAPTER   XII. 

EMPHYSEMA,    ASTHMA,    PULMONARY   SYPHILIS,  ETC. 

I.  Emphysema. 

For  clinical  purposes,  the  great  majority  of  cases  of  emi)liy- 
sema  may  be  divided  into  two  groups. 

(1)  Large-lunged  emphysema,  usually  associated  with  chronic 
bronchitis  and  asthma. 

(2)  Small-lunged,  or  senile,  emphysema. 

Although  the  second  of  these  forms  is  exceedingly  common,  it 
is  so  much  less  likely  than  the  first  form  to  ^ixe  rise  to  distressing 
symptoms  that  it  is  chiefly  the  large-lunged  emphysema  which  is 
seen  by  the  physician.  In  both  conditions  we  have  a  dilatation 
and  finally  a  breaking  do^vn  of  the  alveolar  Avails  until  the  air  spaces 
ai"e  become  relatively  large  and  inelastic.  In  both  forms,  the  elas- 
ticity of  the  lung  is  diminished ;  but  in  the  large-lunged  form  we 
have  an  increase  in  the  volume  of  the  whole  organ  in  addition  to 
the  changes  just  mentioned. 

Large-Lunged  EmjtJiysema. 

The  diagnosis  can  usually  be  made  by  inspection  alone.  In 
typical  cases  the  antero-posterior  diameter  of  the  chest  is  greatly 
increased,  the  in-spaces  are  Avidened,  and  the  costal  angle  is  blunted, 
Avhile  the  angle  of  LudAvig'  becomes  prominent.  The  shoulders  are 
high  and  stooping  and  the  neck  is  short  (see  Fig.  130).  The  patient 
is  often  considerably  cyanosed,  and  his  breathing  rapid  and  difficult. 
Inspiration  is  short  and  harsh ;  expiration  prolonged  and  difficult. 
The  ribs  moA-e  but  little,  and,  owing  to  the  ossification  of  their  car- 

•  Formed  by  the  junction  of  the  manubrium  with  the  second  piece  of  the 
sternum. 


EMPHYSEMA,  ASTHMA,  PULMONARY  SYPHILIS,  ETC.     259 


tilages,  are  apt  to  rise  and  fall  as  if  made  in  one  piece  (en  cui- 
rasse).  The  working  of  the  auxiliary  muscles  of  respiration  is  not 
infrequently  seen.  The  diaphragm  shadow  (Litten's  sign)  begins 
its  excursion  one  or  two  ribs  farther  down  than  usual  and  moves  a 
much  shorter  distance  than  in  normal  cases. 

Paljiittion  shows  a  diminution  in  the  tactile  fremitus,  through- 
out the  affected  portions;  that  is,  usually  throughout  the  whole  of 
both  lungs.  Sometimes  it  is 
scarcely  to  be  perceived  at  all. 

Percussion  yields  very  in- 
teresting information.  The 
disease  manifests  itself — 

(a)  By  hyper-resonance  on 
percussion,  with  a  shade  of 
tympanitic  quality  in  the  note. 

{b)  By  the  extension  of  the 
margins  of  the  lung  so  that 
they  encroach  upon  portions  of 
the  chest  not  ordinarily  reso- 
nant. 

The  degree  of  hyper-reso- 
nance depends  not  only  upon 
the  degree  of  emphysema  but 
upon  the  thickness  of  the  chest 

walls.  The  note  is  most  resonant  and  has  most  of  the  tympanitic 
quality  when  the  disease  occurs  in  old  persons  with  relatively  thin 
chest  walls.  The  encroachment  of  the  over-voluminous  lungs  upon 
the  liver  and  heart  is  demonstrated  by  the  lowering  of  the  line  of 
liver  flatness  from  its  ordinary  position  at  the  sixth  rib  to  a  point 
one  or  two  interspaces  farther  down  or  even  to  the  costal  margin, 
while  the  area  of  cardiac  dulness  may  be  altogether  obliterated, 
the  lungs  completely  closing  over  the  surface  of  the  heart.  At  the 
apices  of  the  lungs  resonance  may  be  obtained  one  or  two  centi- 
metres higher  than  normally  and  the  quality  may  be  markedly  tym- 
panitic. In  the  axillge  and  in  the  back  the  pulmonary  resonance 
extends  down  one  inch  or  more  below  its  normal  position. 


Fic;.  130.— liairel  Cliest  due  to  Chronic  Bron- 
chitis and  Emphysema. 


260    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

Auscultation  shows  in  uncomplicated  cases  no  very  marked  mod- 
ification of  the  inspiratory  murmur,  Avnich,  however,  may  be  short- 
ened and  enfeebled.  The  most  striking  change  is  a  (/reat  prolontja- 
tion  and  enfeeblement  of  expiration,  with  a  lowering  of  its  pitch 
(see  Fig.  131). 

This  type  of  breathing  is  like  bronchial  breathing  in  one  re- 
spect; namely,  that  in  both  of  them  expiration  is  made  prolonged, 
but  emphysematous  breathing  is  feeble  and  low- 
pitched,  while  bronchial  breathing  is  intense 
and  high-pitched.  At  the  bases  of  the  lungs 
the  respiration  is  especially  feeble  and  may  be 
altogether  replaced  by  crackling  rales. 

In  "  small-lunged  emphysema "  we  have 
precisely  the  same  physical  signs,  except  that 
Illustrate  Emphyse-  ^^®  boundaries  of  the  lung  are  not  extended, 
ma  to  us    Breathing      expiration  is  less  prolonged  and  less  difficult, 

with  Musical  Expira-  ,.         ...  .  i  t,t  ,,i 

tory  Rales.  and  mspiration  is  normal.      It  does  not  tend 

to  be  complicated  by  bronchitis  and  asthma; 
indeed  the  small-lunged  emphysema  rarely  gives  rise  to  any  symp- 
toms, and  is  discovered  as  a  matter  of  routine  physical  examination. 

Summary. 

1.  Hyper-resonance  on  percussion. 

2.  Feeble  breathing  with  prolonged  expiration. 

3.  Diminished  fremitus  and  voice  sounds. 

4.  Encroachment  of  the  resonant  lungs  on  the  heart  and  liver 
dulness  (in  the  large-lunged  form). 

Differential  Diagnosis. 

(a)  Emphysema  VL\2iy  be  confounded  with,  pneumothorax,  since  in 
both  conditions  hyper-resonance  aaid  feeble  breathing  are  present. 
But  emphysema  is  usually  bilateral,  encroaches  upon  but  does  not 
displace  neighboring  organs,  and  is  not  often  associated  with  hydro- 
thorax.  Emphysema,  if  extensive,  is  usually  associated  with 
chronic  bronchitis  and  so  with  squeaking  or  bubbling  r^les,  while  in 


EMPHYSEMA,  ASTHMA,  PULMONARY  SYPHILIS,  ETC.     261 

pneumothorax  breathing  is  absent    or   distant   amphoric  without 
rales. 

(b)  The  signs  of  aneurism  of  the  aorta  pressing  on  the  trachea 
or  on  a  primary  bronchus  are  sometimes  overlooked  because  the  fore- 
ground of  the  clinical  picture  is  occupied  by  the  signs  of  a  coexist- 
ing bronchitis  with  emphysema.  The  cough  and  wheezing  which 
the  presence  of  the  aneurism  produces  may  then  be  accounted  for 
as  part  of  the  long-standing  bronchitis,  and  the  duhiess  and  thrill 
over  the  upper  sternum  to  which  the  aneurism  naturally  gives  rise 
may  be  masked  by  extension  of  lung  borders.  But  the  evidence  of 
pressure  on  mediastinal  nerves  and  vessels  (aphonic,  unequal  pulses 
or  pupils,  etc.),  and  the  presence  of  a  diastolic  shock  and  tracheal 
tug  are  usually  demonstrable ;  the  danger  is  that  we  shall  forget  to 
look  for  them. 

(c)  Uncompensated  mitral  stenosis  may  produce  dyspnoea  and 
cyanosis  and  weak  rapid  heart  action  somewhat  similar  to  that  seen 
in  emphysema,  and  may  not  be  associated  with  any  cardiac  mur- 
mur, but  the  dyspnoea  is  not  of  the  expiratory  type,  and  the  irregu- 
larity of  the  heart,  with  evidence  of  dropsy  and  general  venous 
stasis,  should  make  it  evident  that  something  more  than  simple  em 
physema  is  present. 

(d)  The  occurrence  of  an  emphysematous  form  of  'phthisis  I 
have  already  mentioned  in  discussing  the  latter  disease  (see  p.  256). 

Emphysema  with  Bronchitis  or  Asthma. 

In  the  great  majority  of  cases,  emphysema  of  the  lungs  is  asso- 
ciated with  chronic  bronchitis  and  very  often  with  asthmatic  parox- 
ysms. Such,  association  is  especially  frequent  in  elderly  men  who 
have  had  a  winter  cough  for  many  years  and  in  whom  arterio-scle- 
rosis  is  more  or  less  well  marked.  In  such  cases  the  prolonged  and 
feeble  expiration  is  usually  accompanied  by  squeaking  and  groaning 
sounds,  or  by  moist  r§,les  of  various  sizes  and  in  various  parts  of 
the  chest.  AVhen  the  asthmatic  element  predominates,  dry  rales 
are  more  noticeable,  and  occur  chiefly  or  wholly  during  expiration, 
while  inspiration  is  reduced  to  a  short,  quick  gasp. 


262     PHYSICAL  DIAGNOSIS  OF  DISEASES   OF  THE  CHEST. 

Interstitial  Emphysema. 

In  rare  cases  violent  paroxysms  of  coughing  may  rupture  the 
walls  of  the  alveoli  so  as  to  allow  the  passage  of  air  into  the  inter- 
stitial tissue  of  the  lung,  from  whence  it  may  work  through  and 
manifest  itself  under  the  skin,  giving  rise  to  a  peculiar  crackling 
sensation  on  palpation,  and  to  a  similar  sound  on  auscultation. 
More  frequently  the  trouble  arises  in  connection  with  a  tracheot- 
omy wound,  the  air  penetrating  under  the  skin  and  producing  a 
downy,  crepitating  swelling. 

"  Comjjlementary  Emphysema." 

When  extra  work  is  thrown  upon  one  lung  by  loss  of  the  func- 
tion of  the  other,  as  in  pleuritic  effusion — a  true  hypertrophy  of  the 
overworked  sound  lung  may  take  place.  The  elasticity  of  the  lung 
is  not  diminished  as  in  emphysema,  but  is  gi-eatly  increased. 
Hence  the  term  complementary  emphysema  should  be  dropped  and 
the  term  complementary  (or  compensatory)  JiypeHrophy  substituted. 

Like  emphysema,  this  condition  leads  to  hyper-resonance  on  per- 
cussion and  to  encroachment  of  the  pulmonary  margins  upon  the 
neighboring  organs  (as  shown  by  a  reduction  in  the  area  of  dulness 
corresponding  to  them),  but  the  respiratory  murmur  is  exafjfjerated 
and  has  none  of  the  characteristics  of  emphysematous  breathing. 

A  word  may  here  be  added  regarding  the  condition  described 
by  West  under  the  name  of 

Acute  Pulmonary  Tympanites. 

In  fevers  and  other  acute  debilitating  conditions  West  has  ob- 
served that  the  lungs  may  become  hyper-resonant  and  somewhat 
tjinpanitic  on  percussion,  owing,  he  believes,  to  a  loss  of  pulmo- 
nary elasticity.  The  tympanitic  note,  often  observable  around  the 
solidified  tissue  in  pneumonia,  is  to  be  accounted  for,  he  believes, 
in  the  same  way.  Like  the  shortening  of  the  first  heart  sound, 
acute  pulmonary  tympanites  points  to  the  weakening  of  muscle  fibre 
which  toxaemia  is  so  apt  to  produce.  Apparently  the  muscle  fibres 
of  the  lung  suffer  like  those  of  the  heart. 


EMPHYSEMA,  ASTHMA,  PULMONARY  SYPHILIS,  ETC.     263 

BRONCHIAL   ASTHMA. 

(Primary  Spasm  of  the  Bronchi). 

During  a  paroxysm  of  bronchial  asthma  our  attention  is  at- 
tracted even  at  a  distance  by  the  loud,  wheezing,  prolonged  expira- 
tion preceded  by  an  abortive  gasping  inspiration.  The  breathing 
is  labored,  much  quickened  in  rate,  and  cyanosis  is  very  marked. 
The  chest  is  distended  and  hyper-resonant,  the  position  of  the  dia- 
phragm low  and  its  excursion  much  limited,  and  the  cardiac  and 
hepatic  dulness  obliterated  by  the  resonance  of  the  distended  lungs. 
On  auscultation,  practically  no  respiratory  murmur  is  to  be  heard 
despite  the  violent  plunging  of  the  chest  walls.  We  hear  squeaks, 
groans,  muscular  rumbles,  and  a  variety  of  strange  sounds,  but 
amid  them  all  practically  nothing  is  to  be  heard  of  the  breath 
sounds.  "  The  asthmatic  storm  flits  about  the  chest,  now  here  now 
there,"  the  rales  appearing  and  disappearing. 

At  the  extreme  base  of  the  lungs  there  may  be  dulness  due  to 
atelectasis  of  the  thin  pulmonary  margins. 

Differential  Diagnosis. 

(a)  Mechanical  irritation  of  the  bronchi,  as  by  the  pressure  of 
an  aneurism  or  enlarged  gland,  may  set  up  a  spasm  of  the  neigh- 
boring bronchioles  much  resembling  that  of  primary  bronchial 
asthma,  but  thorough  examination  should  reveal  other  evidence 
of  mediastinal  pressure,  and  the  history  of  the  case  is  very  different 
from  that  of  asthma. 

(b)  Spasm  of  the  glottis  produces  a  noisy  dyspnoea,  but  the  diffi- 
culty is  with  insjnration,  instead  of  with  expiration,  and  the  crow- 
ing or  barking  sound  is  not  like  the  long  wheeze  of  asthma.  No 
rales  are  to  be  heard,  and  the  signs  in  the  lungs  are  those  of  col- 
lapse instead  of  the  distention  characteristic  of  asthma. 

(c)  The  paroxysmal  attacks  of  dyspncea,  which  often  occur  in 
chronic  nephritis,  myocarditis,  and  other  diseases  of  the  heart  and 
kidney,  may  be  entirely  indistinguishable  from  primary  bronchial 
asthma  but  for  the  evidence  of  the  underlying  cardiac  or  renal  dis- 


264    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

ease.  As  a  rule,  however,  the  element  of  spasm  is  much  less 
marked ;  the  breathing  is  quick  and  labored  but  not  wheezing,  expi- 
ration is  less  prolonged,  and  the  squeaking  and  groanmg  rales  of 
asthma  are  not  present. 

SYPHILIS   OF  THE    LUNG. 

The  diagnosis  cannot  be  made  with  certainty  from  the  physical 
signs,  and  rests  entirely  (in  the  rare  cases  in  which  it  is  made  at  all) 
on  the  history,  the  evidence  of  syphilis  elsewhere  in  the  body,  and 
the  result  of  treatment.     Most  cases  are  mistaken  for  phthisis. 

Any  case  supposed  to  be  phthisis,  but  in  which  the  examination 
of  the  sputa  for  tubercle  bacilli  is  repeatedly  negative,  should  be 
given  a  course  of  syphilitic  treatment. 

The  physical  signs,  as  in  phthisis,  are  those  of  localized  bron- 
chitis or  of  solidification,  but  the  lesions  are  not  at  the  apex  but 
usually  about  the  root  of  the  lung  or  lower  down.  Cavities  are  not 
formed.  Stenosis  of  a  bronchus  may  occur  with  resulting  atelecta- 
sis of  the  corresponding  lobules. 

Bronchiectasis  (Bronchial  Dilatation). 

This  rare  disease  is  still  more  rarely  to  be  recognized  during 
life.  It  is  suggested  by  the  history  of  raising  within  a  few  seconds 
or  minutes  a  very  large  amount  of  sputa,  a  pint  or  more  in  marked 
cases.  The  physical  signs  may  not  be  in  any  way  distinctive,  or 
may  be  those  of  pulmonary  cavity  due  to  tuberculosis.  From  the 
latter  bronchiectasis  is  to  be  distinguished  in  some  cases  by  a 
knowledge  of  the  previous  history.  Signs  of  cavity  in  phthisis  are 
preceded  and  surrounded  by  signs  of  solidification  in  the  same  area, 
while  in  bronchiectasis  this  is  not  the  case.  Again,  a  bronchiecta- 
tic  cavity  is  apt  to  occur,  not  at  the  apex,  as  in  phthisis,  but  in  the 
middle  and  lower  thirds  of  the  lung  posteriorly.  Aside  from  the 
history  and  situation  of  the  cavity  and  the  presence  or  absence  of 
solidification  around  it,  we  cannot  tell  from  physical  signs  whether 
it  be  due  to  tuberculosis  or  to  dilatation  of  a  bronchus.  In  either 
case  we  have  the  signs  discussed  on  page  254  (cracked-pot  reso- 


EMPHYSEMA,  ASTHMA,  PULMONARY  SYPHILIS,  ETC.     265 

nance,  amphoric  breathing  and  voice  sounds,  coarse  gurgling  or 
splashing  sounds  on  cough)— all  these  signs  disappearing  when  the 
cavity  becomes  filled  with  secretions. 

The  disease  may  cause  marked  retraction  of  the  chest  on  the 
affected  side,  and  neighboring  organs  may  be  drawn  out  of  place. 

Cirrhosis  of  the  Lung. 
(Chronic  Interstitial  Pneumonia.) 

As  an  end  stage  of  unresolved  croupous  pneumonia,  or  as  a 
result  of  chronic  irritation  from  mineral  or  vegetable  dust,  a  shrink- 
age of  a  part  or  the  whole  of  the  lung  may  occur,  which  progresses 
until  the  pulmonary  tissue  is  transformed  into  a  fibrous  mass  en- 
closing bronchi. 

The  side  of  the  chest  corresponduig  to  the  affected  lung  becomes 
shrunken  and  concave ;  fremitus  is  increased,  percussion  resonance 
diminished  or  lost,  respiration  tubular  with  coarse  rales. 

From  tuberculosis  the  condition  is  to  be  distinguished  solely  by 
the  history,  the  absence  of  bacilli  in  the  sputa,  and  the  comparative 
mikhiess  of  the  constitutional  symptoms. 

The  right  ventricle  of  the  heart  may  become  hypertrophied  and 
later  dilated  with  resulting  tricuspid  insufficiency. 


CHAPTER  XIII. 

DISEASES   AFFECTING   THE   PLEUEAL   (^WITY. 

I.  Hydrothorax. 

In  cases  of  nephritis  or  of  cardiac  weakness  due  to  valvular 
heart  disease  a  considerable  accumulation  of  serum  may  take  place 
in  both  pleural  cavities.  The  physical  signs  are  identical  with 
those  of  pleuritic  effusion  (see  below,  page  273)  except  that  the 
latter  is  almost  always  unilateral,  while  hydrothorax  is  usually  bi- 
lateral. Exceptions  to  this  rule  occur,  however,  especially  on  the 
right  side  or  in  cases  in  which  one  pleural  cavity  has  been  obliter- 
ated by  fibrous  adhesions,  the  results  of  an  earlier  pleurisy.  The 
fluid  obtained  by  tapping  in  cases  of  hydrothorax  is  usually  con- 
siderably lower  in  specific  gravity  and  poorer  in  albumin  than  that 
exuded  in  pleuritic  inflammation. 

The  fluid  shifts  more  readily  with  change  of  position  than  is  the 
case  with  many  pleuritic  effusions,  owing  to  the  absence  of  adhe- 
sions in  hydrothorax. 

Friction  sounds,  of  course,  do  not  occur,  as  the  pleural  surfaces 
are  not  inflamed.  A  few  grains  of  potassium  iodide  by  mouth  soon 
produce  a  reaction  for  iodine  in  the  fluid  of  hydrothorax  and  not  in 
pleuritic  effusion. 

II     PXEUMOTHORAX. 

Pneumothorax,  or  the  presence  of  air  in  the  pleural  cavity,  may 
result  from  stabs  or  wounds  of  the  chest  wall,  but  is  usually  a  com- 
plication of  pulmonary  tuberculosis  which  weakens  the  lung  until 
by  a  slight  cough  or  even  by  the  movements  of  ordinary  respiration 
the  pulmonary  pleura  is  ruptured  and  air  from  within  the  lung  leaks 
into  the  pleural  cavity. 

If  the  opening  is  of  considerable  size,  and  the  air  is  not  hindered 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.         267 

or  encapsulated  by  adhesions,  great  and  sudden  dysjjnoea  with  pain 
and  profound  "shock  "  may  result.  More  commonly  the  air  enters 
the  pleural  cavity  gradually,  the  other  lung  has  time  to  hyper- 
trophy, and  the  heart  and  other  organs  become  gradually  accus- 
tomed to  their  new  situations. 

Physical  Signs. 

1.  Insjyection. — The  affected  side  may  lag  behind  considerably  in 
the  movements  of  respiration.  In  very  marked  cases  it  is  almost 
motionless  and  the  interspaces  are  more  or  less  obliterated.  The 
diaphragm  is  much  depressed  and  Litten's  sign  absent.  In  right- 
sided  pneumothorax,  which  is  relatively  rare,  the  liver  is  depressed 
and  the  edge  can  be  felt  below  the  ribs. 

The  heart  is  displaced  as  by  pleuritic  effusion,  but  usually  to  a 
less  extent.  With  left-sided  pneumothorax  the  cardiac  impulse 
may  be  lowered  as  well  as  displaced,  owing  to  the  descent  of  the 
diaphragm. 

2.  Pa/pat  ion. — Fremitus  is  absent  over  the  lower  portions  of  the 
chest  corresponding  to  the  effused  air.  At  the  stimmit  of  the  chest 
over  the  retracted  lung,  fremitus  may  be  normal  or  increased.  In 
rare  cases  when  the  lung  is  adherent  to  the  chest  wall  and  cannot 
retract,  fremitus  is  preserved. 

The  positions  of  the  heart  and  liver  are  among  the  most  impor- 
tant points  determined  by  palpation.  Xot  infrequently  no  cardiac 
impulse  is  to  be  obtained.  Sometimes  it  may  be  felt  to  the  right 
of  the  sternum  (see  Fig.  132)  or  in  the  left  axilla,  but  not  infre- 
quently it  is  so  fixed  by  pleuropericardial  adhesions  that  it  is  drawn 
upward  toward  the  retracted  lung  or  remains  near  its  normal  situa- 
tion. The  liver  is  greatly  depressed  in  cases  of  right-sided  pneumo- 
thorax, and  may  be  felt  as  low  as  the  navel. 

3.  Percussion. — Loud  tympanitic  resonance  is  the  rule  through- 
out the  affected  side.  Even  a  small  amount  of  air  is  sufficient  to  ren- 
der the  whole  side  tympanitic  and  often  to  obscure  the  dulness  which 
the  frequently  associated  pleural  effusion  would  naturally  produce. 
Indeed,  it  is  the  rule  that  small  effusions  are  wholly  masked  by  the 
adjacent  tympany. 


268    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

In  no  other  disease  do  we  get  such  clear,  intense  tympanitic 
resonance  over  the  chest. 

The  only  exception  to  this  rule  occurs  in  cases  in  which  the  air 
within  the  chest  is  under  great  tension,  making  the  chest  walls  so 
taut  that,  like  an  over-stretched  drum,  they  cannot  vibrate  properly. 
Under  these  conditions  the  percussion  note  becomes  muffled,  at 
times  almost  dull. 

Areas  of  dulness  corresponding  to  the  displaced  organs  (heart 
or  liver)  may  sometimes  be  percussed  out. 

4.  Auscultation. — Respiration  and  voice  sounds  are  usually  in- 
audible in  the  lower  portions  of  the  chest.  At  the  top  of  the  chest, 
and  rarely  in  the  lower  parts,  a  faint  amphoric  or  metallic  breathing 
may  be  heard,  but  as  a  rule  the  amphoric  quality  is  brought  out 
much  better  by  cough  which  is  followed  by  a  ringing  after-echo. 
Or  the  air  in  the  pleura  may  be  set  to  vibrating  and  made  to  give 
forth  its  characteristic,  hollow,  ringing  sound  if  a  piece  of  metal 
{e.g.,  a  coin)  be  placed  on  the  back  of  the  chest  and  struck  with 
another  coin,  while  we  listen  with  the  stethoscope  over  the  front  of 
the  chest  opposite  the  point  where  the  coin  is. 

The  clear  ringing  sound  heard  in  this  way  is  qviite  different 
from  the  dull  chink  obtainable  over  sound  lung  tissue. 

The  "falling-drop  sound"  or  "metallic  tinkle,"  and  the  lung 
fistula  sound  are  occasionally  audible  (see  above,  p.  112). 

On  the  sound  side  the  breath  sounds  are  exaggerated.  At  the 
top  of  the  affected  side  over  the  collapsed  lung  the  breathing  is 
bronchial  and  rales  are  occasionally  heard. 

In  the  great  majority  of  cases  pneumothorax  is  complicated  by 
an  effusion  of  fluid  in  the  affected  pleural  cavity  and  we  have  then 
the  signs  of 

III.  Pneumohydrothorax  or  Pneumopyothorax. 

"When  both  fluid  and  air  are  contained  in  the  pleural  cavity,  the 
patient  may  himself  be  able  to  hear  the  splashing  sounds  which 
the  movements  of  his  own  body  produce.  These  are  more  readily 
appreciated  if  the  observer  puts  his  ear  against  the  patient's  chest 
and  then  shakes  him  briskly.     Splashing  sounds  heard  within  the 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.         269 

chest  are  absolutely  pathognomonic  and  point  only  to  the  combina- 
tion of  fluid  and  air  within  the  pleural  cavity.  One  must  distin- 
guish them,  however,  from  similar  sounds  produced  in  the  stomach. 
By  observing  the  position  of  maximum  intensity  of  the  sounds,  this 
distinction  may  be  easily  made.  Unfortunately  the  critical  condi- 
tion of  the  patient  may  make  it  impossible  to  try  succussion,  as  in 
the  acute  cases  with  great  shock  it  is  dangerous  to  move  him  at  all. 
The  movements  of  breathing  or  coughing  may  bring  out  a  "  metal- 
lic tinkle  "  (see  above,  p.  112).     At  the  base  of  the  chest,  over  an 

I  Tuberculous  so- 

I  I  ,^'    lidlflcation. 


Exaggerated         /    .^^--^^^'P-^'yl^^---^^ 
resonance  and "--//'      jy    /K  ^^^^^^=^^~?yV     Nl      ^  \ 
breathing.  i      I  ^7^ ~ a\"--r':^^^^^j</M        v~    /    \ 

I  /lK~:rT=^^^^^^^;n—VM  I  \  absent  voice ; 

I  ---J-')l\r'"^''''^^^^'^Nr~^^^^A'~|[ 1- -Alr=-?  breathing  ab- 

Dlsplacedeardiac '   A  ft^^^:rr^<)i    /VV^X:::^    A  sent  or  distant 

impulse.  \  KS^yO\J\^^M  /  *  '-  am  phone. 

1  w's^/  ^^^^-/---  Dulness,    shifting 

\  rcP  /  \^S;  /  ~ with  change  of  po- 

\k2/  \^  sition=  (fluid). 


Fig.  132.— Pneumohydrothorax  with  Displaced  Heart. 

area  corresponding  to  the  position  of  the  fluid,  an  area  of  dulness 
may  be  easily  marked  out  by  percussion,  and  this  area  shifts  venj 
markedhj  with  change  of  position.  The  shiftmg  dulness  of  pneu- 
mohydrothorax is  strongly  in  contrast  with  the  difficulty  of  obtain- 
ing any  such  shift  in  ordinary  pleuritic  effusion  (see  Fig   132) 

(The  distinction  between  '^ open  pneumothorax,"  in  which  the 
rent  in  the  lung  through  which  the  air  escaped  in  the  pleura  re- 
mains open,  and  "closed  pneumothorax,''  in  which  the  rent  has 
become  obliterated— is  one  which  cannot  be  established  by  physi- 
cal signs  alone.  It  is  often  said  that  amphoric  breathing,  and  espe- 
cially an  amphoric  ring  to  the  voice  and  cough  sounds,  denote  an 


270    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

open  pneumothorax,  but  post-mortem  evidence  does  not  bear  this 
out.  Practically  an  open  pneumothorax  is  one  in  which  the 
amount  of  effused  air  increases,  and  closed  pneumothorax  is  one  in 
which  the  physical  signs  remain  stationary  ) 

Differential  Diagnosis 

The  distinction  between  pneumothorax  and  emphysema  has  al- 
ready been  discussed  (see  p.  260). 

(a)  When  the  air  in  the  pleural  sac  is  under  such  tension  that 
the  percussion  note  is  dull,  the  physical  signs  may  simulate  })leu- 
ritic  effusion,  but  real  flatness,  such  as  characterizes  effusion,  has 
not,  so  far  as  I  know,  been  recorded  in  pneumothorax,  and  the 
sense  of  resistance  on  percussing  is  much  greater  over  fluid  than 
over  air.     In  case  of  doubt  puncture  is  decisive. 

(b)  Acute  pneumothorax,  coming  on  as  it  does  with  symptoms 
of  collapse  and  great  shock,  may  be  mistaken  for  angina  pectoris, 
cardiac  failure,  embolism  of  the  pulmonary  artery,  or  acute  ))ulmo- 
naiy  tympanites  (see  above,  p.  202). 

From  all  these  it  can  be  distinguished  by  the  presence  of  am- 
phoric or  metallic  sounds,  which  are  never  to  be  obtained  in  the 
other  affections  named. 

(c)  Hernia  of  the  intestine  through  the  diaphragm,  or  great 
weakening  of  the  diaphragmatic  muscular  fibres,  may  allow  the 
intestines  to  encroach  upon  the  thoracic  cavity  and  simulate  pneumo- 
thorax very  closely.  The  history  and  course  of  the  case,  the  ab- 
dominal pain,  vomiting,  and  indicanuria,  generally  suffice  to  distin- 
guish the  condition.  The  peristalsis  of  the  intestine  may  go  on  even 
in  the  thorax,  and  gurgling  metallic  sounds  corresi^onding  to  it  and 
luiiike  anything  produced  in  the  thorax  itself  may  be  audible 

The  distinction  between  open  and  closed  pneumothorax,  to  which 
I  have  already  alluded,  is  far  less  important  than  the  presence  or 
absence  of 

(a)  Pulmonary  tuberculosis 

(b)  Encapsulating  adhesions  in  which  the  air  is  confined  to  a 
circumsci"ibed  area 

(a)  TJie  examination  of  the  sputa  and  of  the  compressed  lung 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.        271 

may  yield  evidence  regarding  tuberculosis.  On  the  sound  side  the 
compensatory  hypertrophy  covers  up  foci  of  dulness  or  rales  so  that 
it  is  difficult  to  make  out  much. 

(l>)  Encapsulated  pneumothorax  gives  us  practically  all  the  signs 
of  a  phthisical  cavity,  from  which  it  is  distinguished  by  the  fact 
that  with  a  cavity  the  nutrition  of  the  patient  is  almost  always 
much  worse. 

Encapsulated  pneumothorax  needs  no  treatment.  Hence  the 
importance  of  distinguishing  it  from  the  non-encapsulated  form  of 
the  disease,  in  which  treatment  is  essential. 

PLEURISY. 

Clinically,  we  deal  with  three  types : 

(a)  Dry  or  plastic  pleurisy. 

(b)  Pleuritic  eifusion,  serous  or  purulent. 

(c)  Pleural  thickening. 

(«)  Dry  ok  Plastic  Pleurisy. 

Doubtless  msiny  cases  run  their  course  without  being  recognized. 
The  frequency  with  which  pleuritic  adhesions  are  found  post  mor- 
tem would  seem  to  indicate  this. 

It  is  usually  the  characteristic  stitch  in  the  side  which  suggests 
physical  examination.  The  pain  and  the  physical  signs  resulting 
from  the  fibrinous  exudation  are  usually  situated  at  the  bottom  of 
the  axilla  where  the  diaphragmatic  and  costal  layers  of  the  jjleura 
are  in  close  apposition.  Doubtless  the  pleuritic  inflammation  is 
not  by  any  means  limited  to  this  spot,  but  it  is  here  that  the  two 
layers  of  the  pleura  make  the  largest  excursion  while  in  apposition 
•with  each  other.  In  the  vast  majority  of  cases,  then,  the  physical 
signs  are  situated  at  the  spot  indicated  in  Fig.  133. 

Occasionally  pleuritic  friction  is  to  be  heard  in  the  precordial 
region,  and  after  the  absorption  of  a  pleuritic  effusion  evidences 
of  fibrinous  exudation  in  the  njiper  parts  of  the  chest  are  sometimes 
demonstrable.  Most  rarely  of  all,  evidence  of  plastic  pleurisy  may 
be  found  at  the  apex  of  the  lung  in  connection  with  early  phthisis. 
Tn  diaphragmatic  pleurisy,  wlieu  the  fibrinous  exudation  is  espe- 


272    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 


cially  marked  iq^on  the  diaphragmatic  pleura,  friction  sounds  may 
be  heard  over  the  region  of  the  attachment  of  the  diaphragm  in 
front  and  behind  as  well  as  m  the  axillse.  Hiccup  often  occurs  and 
gives  exquisite  pain. 

Our  diagnosis  is  based  upon  a  single  physical  sign,  ^>Ze»r/^/c 
friction.  The  nature  of  this  sound  and  the 
manoeuvres  for  eliciting  it  have  already 
been  described  (see  above,  p.  108),  and  I 
will  here  only  recapitulate  what  was  there 
said.  During  the  first  few  deep  breaths 
one  hears,  while  listenmg  over  the  painful 
area,  a  grating  or  rubbing  sound  usually 
somewhat  jerky  and  mterrupted,  most 
marked  at  the  latter  part  of  inspiration, 
but  often  audible  throughout  the  Avhole 
respiratory  act.  After  a  few  breaths  it 
often  disappears,  but  will  usually  reap- 
pear if  the  patient  lies  for  a  short  time 
upon  the  affected  side,  and  then  sits  up 
and  breathes  deeply.  In  marked  cases 
the  rubbing  of  the  inflamed  pleural  sur- 
faces may  be  felt  as  well  as  heard,  and  it 
is  not  very  rare  for  the  patient  to  be  able 
to  feel  and  hear  it  himself.  Pleuritic  fric- 
tion may  be  present  and  loud  Avithout 
giving  rise  to  any  pain.  On  the  other 
hand,  the  pain  may  be  intense,  and  yet 
the  friction-rub  barely  audible.  Wlien 
heard  at  the  summit  of  the  chest,  as  in 
cases  of  incipient  phthisis,  pleural  fric- 
tion produces  only  a  faint  grazing  sound,  much  more  delicate  and 
elusive  than  the  sounds  produced  at  the  base  of  the  chest. 

Occasionally  the  distinctive  rubbing  or  grating  sounds  are  more 
or  less  commingled  with  or  replaced  by  crackling  sounds  indistin- 
guishable from  the  drier  varieties  of  rales.  It  is  now,  I  think, 
generally  believed  that  such  sounds  may  originate  in  the  pleura  as 


Fig.  133.— Showing  the  Point  at 
which  Pleural  Friction  is  most 
Often  Heard. 


DISEASES  AFFECTiya  THE  PLEURAL  CAVITY.  273 

well  as  within  the  lung.  The  greatest  care  should  be  taken  to 
prevent  any  shifting  or  slipping  of  the  stethoscope  upon  the  surface 
of  the  chest,  as  by  such  means  sounds  exactly  like  those  of  pleural 
friction  may  be  transmitted  to  the  ear.  In  case  of  doubt  one 
should  always  wet  or  grease  the  skin  so  that  the  stethoscope  can- 
not slip. 

Muscle  sounds  are  sometimes  taken  for  pleural  friction,  but  they 
are  bilateral,  usually  low-pitched,  sound  less  superficial  than  pleu- 
ral friction,  and  are  not  increased  by  pressure.  When  listening 
for  friction  at  the  base  of  the  left  axilla,  I  have  once  or  twice  been 
puzzled  by  some  low-pitched  rumbling  sounds  occurring  at  the  end 
of  inspiration,  and  due  (as  afterward  appeared)  to  gas  in  the  stom- 
ach which  shifted  its  position  with  each  descent  of  the  diaphragm. 

In  children  friction  sounds  and  pleuritic  pain  are  much  less 
common  than  in  adults,  and  the  signs  first  recognizable  are  those 
of  effusion.  In  adults  the  presence  of  a  very  thick  layer  of  fat 
may  make  it  difficult  or  impossible  to  feel  or  hear  pleural  friction. 

The  breath  sounds  over  the  affected  area  are  usually  absent  or 
greatly  diminished,  owing  to  the  restraint  in  the  respiratory  move- 
ments due  to  pain.  Not  infrequently  pleuritic  friction  may  be 
heard  altogether  below  the  level  of  the  lung. 

(i)  Pleuritic  Effusiojt. 

Many  cases  are  latent,  and  the  patients  consult  the  physician  on 
account  of  slight  cough,  weakness,  or  gastric  trouble,  so  that  the 
effusion  is  first  discovered  in  the  course  of  routine  physical  ex- 
amination. Since  it  is  usually  the  results  of  percussion  which  first 
put  us  on  the  right  track,  I  shall  take  up  first 

Percussion. 

1.  A  small  effusion  first  shows  as  an  area  of  dulness 

(a)  Just  below  the  angle  of  the  scapula. 

(b)  In  the  left  axilla  between  the  fifth  and  the  eighth  rib. 

(c)  Obliterating  Traube's  semilunar  area  of  tympany;  or 

(d)  In  the  right  front  near  the  imgle  made  by  the  cardiac  and 
hepatic  lines  of  dulness  (see  Fig.  134). 

18 


274    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

In  the  routine  percussion  of  the  chest,  therefore,  one  should 
never  leave  out  these  areas.  A  small  effusion  is  most  easily  de- 
tected in  children  or  in  adults  with  thin  chest  walls,  provided  our 
percussion  is  not  too  heavy.  An  effusion  amounting  to  a  pint 
should  always  be  recognizable,  and  smaller  amounts  have  frequently 
been  diagnosed  and  proved  by  puncture. 

The  amount  of  a  pleuritic  effusion  is  roughly  proportional  to 
the  area  of  dulness  on  percussion,  but  not  accurately.  It  is  very 
common  to  find  on  puncture  an  amoiant  of  fluid  much  greater  than 


Area   of   dulness 

due     to     small  -c-f^ 1~ 

pleural  effusion. 


-  Area  of  cardiac 
dulness. 


Fig.  134.— Small  Pleural  Effusion  Accumulating  (in  part)  near  the  Right  Border  of  the  Heart. 


could  have  been  suspected  from  the  percussion  outlines ;  on  the  other 
hand,  the  dulness  may  be  extensive  and  intense  on  account  of  great 
inflammatory  thickening  of  the  costal  pleura,  by  the  accumulation 
of  layer  after  layer  of  fibrinous  exudate  and  its  organization  into 
fibrous  plates,  while  very  little  fluid  remains  within. 

The  amount  of  dulness  depends  also  upon  the  thickness  and  elasti- 
city of  the  chest  wall  and  the  degree  of  collapse  of  the  lung  within. 

2.  Large  Effusions. — When  the  amount  of  fluid  is  large,  the  dul- 
ness may  extend  throughout  the  whole  of  one  side  of  the  chest  with 
the  exception  of  a  small  area  above  the  clavicle  or  over  the  primary 
bronchus  in  front.     This  area  gives  a  high-pitched  t7jmpanitic  note, 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.  275 

provided  the  bronchi  remain  open,  as  they  almost  always  do.  This 
tympany  is  high-pitched  and  sometimes  astonishingly  clear.  I  re- 
cently saw  a  case  in  which  the  note  above  the  clavicle  was  almost 
indistinguishable  with  the  eyes  shut  from  that  obtained  in  the  epi- 
gastrium. Occasionally  "  cracked-pot "  resonance  may  be  obtamed 
in  the  tympanitic  area. 

The  pitch  changes  if  the  patient  opens  and  closes  his  mouth 
while  we  percuss  ("Williams'  tracheal  tone"). 

The  dulness  over  the  lower  portions  of  a  large  effusion  is  usual- 
ly vevi/  marked,  and  the  percussing  finger  feels  a  greatly  increased 

Normal     resonance   '^^^^ 
and    vesicular 
breathing. 


Tympany,  voice  and    — 
fremitus     In- 
creased. 


Flatness,  no  breath- 
ing', voice  sounds, 
or  fremitus. 


Zone  of  condensed 
lung  above  the 
fluid. 


.  Exaggerated  (com- 
pensatory) breath- 
ing and  reso- 
nance. 


Fig.  135.— Diagram  to  Illustrate  Physical  Signs  in  Moderate-Sized  Effusion  in  the  Left  Pleura. 


resistance  to  its  blows  when  compared  with  the  elastic  rebound  of 
the  sound  side. 

3.  Moderate  Effusions. — Three  zones  of  resonance  can  often  be 
mapped  out  in  the  back:  at  the  base  dulness  or  flatness,  above 
that  a  zone  of  mingled  dulness  and  tympany,  and  at  the  top  normal 
resonance.  The  lowest  zone  corresponds  to  the  fluid,  the  middle 
zone  to  the  condensed  lung  immediately  above  it,  and  the  top  zone 
to  the  relatively  unaffected  part  of  the  lung  (see  Fig.  135).  Not 
infrequently  there  is  no  middle  zone  but  simply  dulness  below  and 
resonance  above,  as  is  usually  the  case  in  the  axilla  and  front 


276    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

The  position  of  the  effusion  depends  only  in  part  upon  the  in- 
fluence of  gravity,  and  is  greatly  influenced  by  capillarity  and  the 
degree  of  retraction  of  the  lungs.  Consequently  the  surface  of 
the  fluid  is  hardly  ever  horizontal  except  in  very  large  accumula- 
tions. With  the  patient  in  an  upright  position  it  usually  reaches 
a  higher  level  in  the  axilla  than  iii  the  back.  Xear  the  spine  and 
near  the  sternum  (in  right-sided  effusions)  the  line  corrresponding 
to  the  level  of  the  fluid  may  rise  sharply. 

The  S-curve  of  Ellis,  as  worked  out  so  elaborately  by  Garland, 
varies  still  further  the  uneven  line  which  corresponds  to  the  sur- 


Trianjfular  space 
(lull  until  patient 
has  coughed  and 
breathed  deeply. 


Area  of  du  Iness 
bounded  above  by 
the  S-curve  of 
Ellis. 


Fig.  136.-The  S-Curve  of  Ellis. 


face  of  the  fluid  (see  Fig.  136).  This  curve  can  be  obtained  only 
after  the  patient  has,  by  cough  and  forced  breathing,  expanded  the 
lung  as  fully  as  possible. 

All  these  curves  are  to  be  found  with  the  patient  in  the  upright 
position.  None  of  them  has  any  considerable  diagnostic  impor- 
tance, and  the  chief  point  to  be  remembered  is  that  the  upper  sur- 
face of  the  fluid,  not  being  settled  by  gravity  alone,  is  hardly  ever 
horizontal. 

With  change  in  the  position  of  the  patient  the  level  of  the  fluid 
sometimes  changes  very  slowly  and  irregulai-ly,  and  sometimes  does 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.  277 

not  change  at  all.  If,  for  purposes  of  thorough  examination,  Ave 
raise  to  a  sitting  posture  a  patient  who  has  been  for  some  days  or 
weeks  in  bed,  we  should  never  begin  the  examination  at  once,  since 
it  may  take  some  minutes  for  the  lungs  and  the  fluid  to  accommo- 
date themselves  to  the  new  position.  It  is  Avell  also  to  get  the 
patient  to  cough  and  to  take  a  number  of  full  breaths  before  the 
examination  is  begun. 

To  test  the  mobility  of  the  fluid  with  change  of  the  patient's 
position,  mark  out  the  upper  limit  of  the  dulness  in  the  back  with 
the  patient  in  the  upright  position.  Then  let  the  patient  lie  face 
downward  upon  a  couch,  and,  after  waiting  a  few  minutes,  percuss 
the  previously  dull  area.     It  may  be  found  to  have  become  resonant.  * 

When  the  fluid  is  absorbed  or  removed  by  tapping,  one  would 
expect  an  immediate  return  of  the  percussion  resonance.  But  in 
fact  the  resonance  returns  A^ery  slowly  and  is  wholly  unreliable  as 
a  test  of  the  amount  of  absorption  which  has  occurred.  Thickened 
pleura  and  atelectatic  lung  may  abolish  resonance  long  after  the 
fluid  is  all  gone.  We  depend  here  far  more  upon  the  evidence  ob- 
tained by  auscultation  and  palpation  and  on  the  general  condition 
of  the  patient. 

To  determine  the  returning  elasticity  of  the  lung  and  the  degree 
of  movability  of  its  loAver  border,  percussion  is  very  useful  during 
the  stage  of  absorption.  After  percussing  out  the  lower  border  of 
pulmonaiy  resonance  in  the  back,  the  patient  is  directed  to  take  a 
long  breath  and  hold  it.  If  the  lung  expands,  the  area  of  percus- 
sion resonance  will  increase  downward. 

Percussion  aids  us  in  determining  whether  neighboring  organs 
are  displaced  by  the  pressure  of  the  accumulated  fluid.  The  liver 
is  often  pushed  doAvn,  the  spleen  ve7'i/  rarely.  Dislocatioyi  of  the 
heaH  is  one  of  the  most  important  of  all  the  signs  of  pleural  effu- 
sion, and  is  often  the  crucial  point  in  differential  diagnosis.     It  is 

'  This  test,  however,  is  somewhat  fallacious  and  of  very  little  diagnostic 
value,  since  the  lungs  tend  to  swing  up  toward  the  back  when  the  patient  lies 
prone,  even  lohen  no  fluid  is  present,  and  increase  of  resonance  in  the  back  with 
this  change  of  position  might,  therefore,  occur  when  the  dulness  was  due  to 
thickened  pleura  and  not  to  fluid. 


278    PHYSICAL  DIAGNOSIS  OF  DISEASES   OF  THE  CHEST. 

a  very  striking  and  at  first  surprising  fact  that  a  left-sided  effvision 
displaces  the  heart  far  more  than  a  right-sided  effusion  of  the  same 
size.  Small  or  moderate  right-sided  eifusions  often  do  not  displace 
the  heart  at  all. 

With  left-sided  effusions,  unless  very  small,  we  find  the  area  of 
cardiac  dulness  shifted  toward  the  right  and  often  projecting  be- 
yond the  right  edge  of  the  sternum  (see  Fig.  134).  (Inspection  and 
palpation  often  give  us  even  more  valuable  information  on  this 
point.  See  below,  j).  281.)  We  must  be  carefvil  to  distinguish  such 
an  area  of  dulness  at  the  right  sternal  margin  from  that  which  may 
be  produced  in  right-sided  effusions  by  the  fluid  itself  (see  above). 

As  mentioned  above,  a  right  pleural  effusion  may  very  early 
show  itself  as  an  area  of  dulness  along  the  right  sternal  margin. 
Light  percussion  will  usually  demonstrate  that  this  dulness  is  con- 
tinuous with  a  narrow  strip  of  flatness  at  the  base  of  the  axilla 
(ninth  and  tenth  ribs).  Such  an  eifusion  is  late  in  creeping  up  the 
axilla.  It  appears  first  and  disappears  first  along  the  right  margin 
of  the  sternum. 

On  the  sound  side  the  percussion  resonance  is  often  increased, 
owing  to  compensatory  hypertrophy  of  the  sound  lung ;  the  dia- 
phragm is  pushed  down  and  the  borders  of  the  heart  or  of  the  liver 
may  be  encroached  upon.  When  the  hyper-resonance  of  the  sound 
side  is  present,  it  should  warn  us  to  percuss  lightly  over  the  effu- 
sion, else  we  may  bring  out  the  resonance  of  the  distended  lung. 

Summary  of  Percussion  SIr/ns. —  (1)  Flatness  corresponding 
roughly  to  the  position  of  the  fluid. 

(2)  Tympany  above  the  level  of  the  fluid  over  the  condensed 
lung. 

(3)  The  level  of  the  fluid  is  seldom  quite  horizontal. 

(4)  Shifting  of  the  fluid  with  change  of  position  is  rare,  slow, 
and  has  little  or  no  importance  in  diagnosis. 

ExcejJtions  and  Possible  Errors. — («)  Great  muscular  pain  and 
spasm  may  produce  an  area  of  dulness  which  simulates  that  of 
pleural  effusions,  especially  as  the  auscultatory  signs  may  be  equally 
misleading.  A  hypodermic  of  morphine  will  dispel  the  dulness 
along  with  the  pain  if  it  is  due  to  muscular  cramp. 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.         279 

(b)  If  the  lung  on  the  affected  side  fails  to  retract  (owing  to 
emphysema  or  adhesions  to  the  chest  wall),  the  area  of  duhiess  and 
its  intensity  will  be  much  diminished. 

(c)  It  must  be  remembered  that  dulness  in  Traube's  space  may 
be  due  to  solidification  of  the  lung,  to  tumors,  or  to  overfilling 
of  the  stomach  and  intestine  with  food,  as  well  as  to  pleural  effu- 
sion ;  also  that  the  size  of  the  tympanitic  space  varies  greatly  in 
health. 

(rf)  Rarely  percussion  may  be  tympanitic  over  an  effusion  at 
the  left  base  owing  to  distention  of  the  stomach  or  colon. 

(e)  The  diagnosis  between  fluid  and  thickened  pleura  will  be 
considered  later. 

Aitscultation. 

The  auscultatory  phenomena  vary  greatly  in  different  cases,  and 
in  the  same  case  at  different  times,  because  the  essential  condi- 
tions are  subject  to  similar  variations.  Whateeer  sounds  are  pro- 
duced hi  the  lunfjs  or  in  the  bronchi  may  he  heard  over  the  fluid  un- 
less interfered  with  hy  inflammatory  thickening  of  the  costal  pleura. 
Fluid  tra?ismifs  sounds  tcell,  but  there  maybe  no  breath  sounds  pro- 
duced and  hence  none  audible  over  the  fluid.  Or  tubular  sounds 
only  may  be  produced  because  only  the  bronchi  remain  open,  the 
rest  of  the  lung  being  collapsed. 

Or  again,  if  rales  or  friction  sounds  are  produced  in  the  lung, 
they,  too,  may  be  transmitted  to  the  fluid  and  may  (alas!)  deter 
the  timid  "  observer  "  from  tapping. 

In  about  two-thirds  of  all  large  effusions  no  breathing  at  all  is 
audible  over  the  area  of  flatness  on  percussion.  In  the  remainmg 
third,  and  especially  in  children,  tubular  breathing,  sometimes 
feeble,  sometimes  very  intense,  is  to  be  heard. 

In  moderate  effusions  there  are  often  three  zones  in  the  back 
At  the  bottom  we  hear  nothing,  in  the  middle  zone  distant  bron- 
chial or  broncho-vesicular  breathing,  while  at  the  summit  of  the 
chest  the  breathing  is  normal. 

The  voice  sounds  correspond  "WTien  breath  sounds  are  absent, 
the  voice  sounds  are  likewise  absent      When  the  breathing  is  tubu- 


280    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

lar,  the  voice,  and  especially  the  whisper,  is  also  tubular  and  inten- 
sified. That  is,  tvhenever  the  bronchi  are  open,  the  lung  retracted, 
and  the  chest  icalls  tJiin,  the  hreathing,  voice,  and  ^chisper  tcill  corre- 
spond to  the  tracheal  and  bronchial  sounds.  Since  children  have  es- 
pecially thin  chest  walls,  these  bronchial  sounds  are  especially  fre- 
quent and  intense  in  children.' 

Near  the  angle  of  the  scapula  and  in  a  corresponding  position 
in  front,  the  somid  of  the  spoken  voice  may  have  a  peculiar  high- 
pitched,  nasal  twang,  to  which  the  term  egophony  is  applied. 
This  sign  has  no  importance  in  diagnosis,  since  it  is  not  constant, 
and  not  peculiar  to  fluid  accumulations 

Rales  are  rarely  produced  in  the  retracted  lung,  and  so  are 
rarely  to  be  heard  over  the  fluid. 

All  these  sounds  may  be  diminished  or  abolished  if  the  costal 
pleura  is  greatly  thickened 

The  influence  of  cough  upon  the  lung,  and  so  upon  the  sounds 
produced  in  it  and  transmitted  through  the  fluid,  may  be  very  great 
and  very  puzzling  Rales  may  appear  or  disappear,  breathing 
change  in  quality  or  intensity,  and  in  the  differential  diagnosis  of 
difficult  cases  the  patient  should  always  be  made  to  cough  and  then 
breathe  deeply  before  the  examination  is  completed. 

In  very  large  effusions,  when  only  the  primary  bronchi  are 
open,  there  may  be  signs  like  those  of  pulmona'y  cavity  at  the  site 
of  the  bronchi  in  front  or  behind  (amY>horic  breathing,  large  metallic 
r§,les,  etc.).  Over  the  sound  lung  the  breathing  is  exaggerated  and 
extends  unusually  far  down  in  the  back  and  axilla,  owing  to  hyper- 
trophy of  the  lung. 

The  heai-t  sounds  may  be  absent  at  the  apex  owing  to  disloca- 
tion of  the  heart.  In  left-sided  effusions  the  apex  sounds  are  often 
loudest  near  the  ensiform.  cartilage  or  beyond  the  right  margin  of 
the  sternum.  Right-sided  effusions  have  much  less  effect  upon  the 
heart,  but  occasionally  we  find  the  heart  sounds  loudest  at  the  left 
of  the  nipple  or  in  the  axilla. 

Since  many  cases  of  pleural  effusion  are  due  to  tuberculosis,  we 

'Bacelli's  theory — that  the  whispered  voice  is  conducted  through  serum 
but  not  through  pus — is  not  borne  out  by  facts. 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.  281 

should  never  omit  to  search  for  evidences  of  this  disease  at  the 
apex  of  the  hmg  on  the  soinid  side,  since  experience  has  shown  that 
phthisis  is  more  apt  to  begin  here  than  on  the  side  of  the  effusion. 

Summari/  of  Auscultutor//  Slyjn.s. 

(1)  In  most  cases  voice  and  breath  sounds  are  absent  or  very 
feeble  over  the  area  occupied  by  the  fluid. 

(2)  In  a  minority  of  the  cases  the  breathing  and  voice  sounds 
may  be  tubular  and  intensified,  especially  in  children. 

(3)  Over  the  condensed  lung  at  the  summit  of  the  chest  the 
breathing  is  bronchial  or  broncho-vesicular,  according  to  the  degree 
of  condensation.  If  the  amount  of  fluid  is  small,  the  layer  of  con- 
densed lung  occupies  the  middle  zone  of  the  chest  and  the  breath- 
ing is  normal  at  the  top  of  the  chest. 

(4)  Rales  and  friction  sounds  are  rarely  heard  over  fluid. 

(5)  On  the  sound  side  the  breathing  is  exaggerated. 

(6)  Tlie  heart  sounds  may  be  absent  at  the  apex  and  present  in 
the  left  axilla  or  to  the  right  of  the  sternvmi  owing  to  dislocation 
of  the  lieart. 

Insj^ection  and  Palpation. 

The  most  important  information  given  us  by  inspection  and 
palpation  relates  to  the  displacement  of  vai'ious  organs  by  the  pres- 
sure of  the  accumulated  fluid.  In  left-sided  pleuritic  effusions  the 
heart  is  usually  displaced  considerably  toward  tlie  right,  even  when 
the  level  of  the  fluid  reaches  no  higher  than  the  sixth  rib  in  the 
nipple  line.  The  apex  impulse  is  to  be  seen  and  felt  to  the  right 
of  the  sternum,  somewhere  between  the  third  and  the  seventh  rib, 
when  a  large  amount  of  fluid  is  present.  With  smaller  effusions 
one  may  find  the  apex  beat  lifting  the  sternum  or  close  to  its  left 
border.     The  position  of  the  heart  may  be  confirmed  by  percussion. 

The  spleen  is  scarcely  ever  displaced. 

Right-sided  effusions  are  far  less  likely  to  displace  the  heart,  and 
it  is  only  when  a  large  amount  of  fluid  is  present  that  the  ai)ex  of 
the  heart  is  pushed  outward  beyond  the  nipple.  Moderate  right- 
sided  effusions  often  produce  no  dislocation  of  the  heart  whatever. 
The  liver  is  often  considerably  pushed  down  by  a  right-sided  pleu- 


282    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

ritic  effusion,  and  its  edge  may  be  palpable  several  inches  below  the 
costal  margui.  Its  upper  margin  cannot  be  determined  by  percus- 
sion, as  it  merges  into  the  flatness  produced  by  the  fluid  accumula- 
tion above  it. 

Tactile  fremitus  is  almost  invariably  absent  or  greatly  dimin- 
ished over  the  areas  corresponding  to  the  fluid;  just  above  the  level 
of  the  fluid  it  is  often  increased. 

Occasionally  a  slight  fulness  of  the  affected  side  may  be  recog- 
nized by  inspection,  and  the  interspaces  may  be  less  readily  visible 
than  upon  the  sound  side.  Bulging  of  the  interspaces  I  have  never 
observed.  "When  the  accumulation  of  fluid  is  large  the  respiratory 
movements  upon  the  affected  side  are  somewhat  diminished,'  the 
shoulder  is  raised,  and  the  spine  curved  toward  the  affected  side. 
The  diaphragm  is  depressed,  and  Litten's  sign  therefore  absent. 

There  are  no  reliable  means  for  distinguishing  purulent*  from 
serous  effusions.  The  whispered  voice  may  be  transmitted  through 
either  pus  or  serum.  But  we  know  that  in  children  two-thirds  of 
all  effusions  are  purulent,  while  in  adults  three-fourths  of  them  are 
serous. 

Physical  Signs  During  Absorjition  of  Pleural  Effusions. 

When  the  fluid  begins  to  disappear,  either  spontaneously  or  as 
a  result  of  treatment,  the  dulness  very  gradually  disappears  and 
the  breath  sounds,  voice  sounds,  and  fremitus  reappear.  In  case 
the  heart  has  been  dislocated,  its  return  to  its  normal  position  is 
often  much  slower  than  one  would  anticipate,  and  indeed  all  the 
physical  signs  are  disappointingly  slow  to  clear  up  even  after  tap- 
ping. Pleural  friction  appears  when  the  roughened  pleural  surfaces, 
which  have  been  held  apart  by  the  fluid,  are  allowed  by  the  disap- 
pearance of  the  latter  to  come  into  apposition  again.  Owing  to  pul- 
monary atelectasis  and  permanent  thickening  of  the  pleura,  con- 
siderable dulness  often  remains  for  weeks  after  the  fluid  has  been 
absorbed. 

'  I  have  purposely  made  but  little  of  the  changes  in  the  shape  of  the  chest 
pro<luced  by  pleuritic  effusions,  as  it  has  seemed  to  me  that  by  far  too  much 
stress  has  usually  been  laid  upon  such  signs. 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.         283 

(<•)  Pleural  Thickexixg. 

In  persons  who  have  previously  suffered  from  pleurisy  with 
effusion,  and  in  many  who  have  never  to  their  knowledge  had  any 
such  trouble,  a  considerable  thickening  of  the  pleural  membrane 
with  adhesion  of  the  costal  and  \-isceral  layers  may  be  manifested 
by  the  following  signs : 

(1)  Dulness  on  percussion,  sometimes  slight,  sometimes  marked. 

(2)  Diminished  vesicular  respiration. 

(3)  Diminished  voice  sounds  and  tactile  fremitus. 

(4)  Absence  of  Litten's  phenomenon  and  diminution  in  the 
normal  respiratoiy  excursion  of  the  chest. 

These  signs  are  most  apt  to  be  found  at  the  base  of  the  lung 
behind  and  in  the  axilla.  Occasionally  a  similar  thickening  may 
be  demonstrated  throughout  the  whole  extent  of  the  pleui-a,  and  the 
lung  failing  to  expand,  the  chest  may  fall  in  as  a  result  of  atmos- 
pheric pi-essure  (see  Fig.  20). 

The  ribs  approximate  and  may  overlap,  the  spine  becomes 
curved,  the  shoulder  lowered,  the  scapula  prominent,  and  the  whole 
side  shrunken.  The  heart  may  be  drawn  over  toward  the  affected 
side. 

In  the  diagnosis  of  pleural  thickening  Rosenbach's  "palpatory 
puncture  "  is  sometimes  our  only  resource.  Under  antiseptic  pre- 
cautions a  hollow  needle  is  pushed  Ijetween  the  ribs  and  into  the 
pleural  cavity.  As  the  needle  forces  its  way  through  the  tough 
fibrous,  or  perhaps  calcified,  pleura,  the  degree  and  kind  of  resist- 
ance ai-e  very  enlightening.  Again,  the  amoimt  of  mobility  of  the 
point  after  the  chest  wall  has  been  pierced  tells  us  whether  the 
needle  is  fi-ee  in  a  ca\-ity,  entangled  in  a  nest  of  adhesions,  or  fixed 
in  a  solid  "  cainified  "  limg.  There  is  no  danger  if  the  needle  is 
sterile. 

EXCAPSULATED    PLEURAL    EfFCSIOX. 

Small  accumulations  of  serum  or  pus  may  be  Availed  off  by  ad- 
hesions so  that  the  fluid  does  not  graWtate  to  tlie  lowest  part  of 
the  pleural  cavity  or  spread  itself  laterally  as  it  would  if  free. 


284     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

Such  localized  effusions  are  most  apt  to  be  found  in  the  lower  axil- 
lary regions  or  behind — sometimes  between  the  base  of  the  lung  and 
the  diaphragm,  and  more  rarely  between  the  lobes  of  one  of  the 
lungs  or  higlier  up.  I  haA'e  twice  seen  an  encapsulated  purulent 
effusion  so  close  to  the  left  margin  of  the  heart  that  the  diagnosis 
of  pericardial  effusion  was  made. 

The  diagnosis  of  encapsulated  pleural  effusion  is  a  difficult  one 
and  oftentimes  cannot  be  made  except  by  puncture.  The  signs  are 
those  of  fluid  in  the  pleura,  but  anomalously  placed.  Even  punc- 
ture may  fail  to  clear  up  the  difficulty,  since  the  needle  may  pass 
entirely  through  the  pouch  of  fluid  and  into  some  structure  behind 
so  that  no  fluid  is  obtained. 

PuLSATixG   Pleurisy  (Empyema  Kecessitatis). 

Under  conditions  not  altogether  understood  the  movements 
transmitted  by  the  heart  to  a  pleural  effusion  (usually  purulent) 
may  be  visible  externally  as  a  circumscribed  pulsating  swelling  near 
the  precordial  region,  or  as  a  diffuse  undulation  of  a  considerable 
portion  of  the  chest  wall.  Sometimes  this  pulsation  is  visible  be- 
cause the  fluid  has  worked  its  way  out  through  the  thoracic  wall 
and  is  covered  only  by  the  skin  and  subcutaneous  tissues,  but  occa- 
sionally pulsation  in  a  pleural  effusion  becomes  visible,  although  no 
such  perforation  of  the  chest  wall  has  occurred. 

The  condition  is  a  rare  one,  and  is  of  importance  only  because  it 
may  be  mistaken  for  an  aneurism,  from  which,  however,  it  should 
be  readily  distinguished  by  the  absence  of  a  palpable  thrill  or  dias- 
tolic shock  and  by  the  evidence  of  fluid  in  the  pleura. 

Differextial  Diagxosis  of  Pleuritic  Effusiox. 

The  folloAving  conditions  are  not  infrequently  mistaken  for 
pleuritic  effusion : 

(1)  Croupous  pneumonia  with  occlusion  of  the  bronchi. 

(2)  Pleural  thickening,  with  pulmonary  atelectasis. 

(3)  Subdiaphragmatic  abscess  or  abscess  of  the  liver. 

In  croupous  pneumonia  with  plugging  of  the  bronchi  one  may 


DISEASES  AFFECTING   THE  PLEURAL  CAVITY.        285 

have  present  all  the  physical  signs  of  pleuritic  effusion  except  dis- 
placement of  the  nehjhhoring  organs.  The  presence  or  absence  of 
such  displacement,  together  with  the  history,  symptoms,  and  course 
of  the  case,  is  therefore  our  mauistay  in  distinguishing  the  two 
diseases. 

From  ordinanj  croupous  pneumonia  (without  occlusion  of  the 
bronchi)  pleuritic  effusion  differs  in  that  it  produces  a  greater  de- 
gree of  dulness  and  a  diminution  of  the  spoken  voice  sounds  and 
tactile  fremitus.  Bronchial  breathing  and  bronchial  whisper  may 
be  heard  either  over  solid  lung  or  over  fluid  accumulation,  although 
the  bronchial  sounds  are  usually  feeble  and  distant  in  the  latter 
condition.  The  displacement  of  the  neighboring  organs  is  of  im- 
portance here  as  in  all  diagnoses  in  which  pleuritic  effusion  is  a 
possibility.  In  pleuritic  effusion  we  can  sometimes  determine  that 
the  line  marking  the  upper  limit  of  dulness  shifts  with  cliange  of 
the  patient's  position.  This  is,  of  course,  impossible  in  pneumo- 
nia. A  few  hard  coughs  may  open  up  an  occluded  bronchus  and 
so  clear  up  the  diagnosis  at  once.  In  doubtful  cases  the  patient 
should  always  be  made  to  cough  and  breathe  deeply  before  the 
examination  is  finished. 

It  should  always  be  remembered  that  one  may  have  both  pneu- 
monia and  pleuritic  effusion  at  the  same  time,  and  that  pneumonia 
is  often  followed  by  a  purulent  effusion.  In  children  the  bronchi 
are  especially  prone  to  become  occluded  even  as  a  result  of  a  simple 
bronchitis,  and  we  must  then  differentiate  between  atelectasis  and 
effusion — in  the  main  by  the  use  of  the  critei-ia  just  described. 

(2)  It  is  sometimes  almost  impossible  to  distinguish  small  fluid 
accumulations  in  the  pleural  cavity  from  pleural  thickening  with 
pulmonary  atelectasis.  In  both  conditions  one  finds  dulness,  dimi- 
nution of  the  voice  sounds,  respiration,  and  tactile  fremitus,  and 
absence  of  Litten's  phenomenon,  but  the  tactile  fremitus  is  usually 
more  diminished  when  fluid  is  present  than  in  simple  pleural  thick- 
ening and  atelectasis.  An  area  of  dulness  which  shifts  with  change 
of  position  points  to  pleuritic  effusion.  The  presence  of  friction 
sounds  over  the  suspected  area  speaks  strongly  in  favor  of  pleural 
thickening,  but  it  is  possible  to  hear  friction  sounds  over  fluid, 


286    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

probably  becaiise  they  are  conducted  from  a  point  higher  up  in  the 
chest  at  which  no  fluid  is  present.  In  doubtful  cases  the  diagnosis 
can  and  should  be  cleared  up  by  ^^jmcfwre. 

(3)  In  two  cases  I  have  known  enlargement  of  the  liver  due  to 
multiple  abscesses  to  be  mistaken  for  empyema.  In  both  condi- 
tions, one  finds  in  the  right  back  dulness  on  percussion  as  high  as 
mid-scapula,  with  absence  of  voice  sounds,  breath  sounds,  and 
fremitus.  These  conditions  are  due  in  one  case  to  the  presence  of 
fluid  between  the  lung  and  the  chest  wall,  and  in  the  other  case  to 


Fig.  137.— Area  of  Dulness  in  Solitary  (tropical)  Abscess  of  the  Liver. 

the  liver  which  pushes  up  the  lung  together  with  the  diaphragm. 
By  physical  signs  alone  I  do  not  see  how  this  diagnosis  is  possible, 
though  Litten's  sign  may  be  of  use,  since  the  shadow  is  absent 
in  empyema  and  sometimes  present  in  moderate-sized  subdia- 
phragmatic accumulations.  Some  of  the  symptoms,  such  as  chills, 
sweating,  and  irregular  fever,  are  common  to  both  conditions.  A 
cai-eful  consideration  of  the  history  and  the  associated  signs  and 
symptoms  may  help  us  to  decide. 

Large  solitary  abscess  of  the  liver,  occurring  as  it  almost  in- 
variably does  in  the  posterior  portion  of  the  right  lobe,  produces  an 
area  of  flatness  on  percussion,  which  rises  to  a  much  higher  level  in 


DISEASES  AFFECTING  THE  PLEURAL  CAVITY.        287 

the  axilla  and  back  than  in  front  or  near  the  sternum  (see  Fig.  137), 
and  may  be  in  this  way  distinguished  from  empyema;  but  when  the 
liver  contains  many  small  abscesses,  as  ua  suppurative  cholangitis, 
this  peculiar  line  of  dulness  is  not  present. 

(d)  Rare  diseases,  such  as  cancer  or  hydatid  of  the  lung,  may 
be  mistaken  for  pleuritic  effusion.  The  history  of  the  case  and  the 
results  of  exploratory  puncture  usually  clear  up  the  difficulty. 


CHAPTER   XIV. 

ABSCESS,  ga:n"grene,  and  cancer  of  the  lung, 

PULMONARY   ATELECTASIS,  (EDEMA,  AND   HYPO- 
STATIC  CONGESTION. 

Abscess  axd  Gangrene  of  the  Lung. 

I  CONSIDER  these  two  affections  together  because  the  physical 
signs,  exclusive  of  the  sputa,  do  not  differ  materially  in  the  two 
affections.  In  some  cases  there  may  be  no  physical  signs  at  all, 
and  the  diagnosis  is  made  from  the  character  of  sputa  and  from  a 
knowledge  of  the  etiology  and  symptomatology  of  the  case.  In 
other  cases  we  find  nothing  more  than  a  patch  of  coarse  rales  or  a 
small  area  of  solidification,  over  which  distant  bronchial  breathing, 
with  increased  voice  sound  and  fremitus,  may  be  appreciated. 
Rarely  there  may  be  slight  dulness  on  percussion,  but  as  a  rule  the 
area  is  not  sufficiently  large  or  sufficiently  superficial  to  produce 
this.  One  may  find  the  signs  of  cavity  (amphoric  breathing, 
cracked-pot  resonance,  and  gurgling  r^les),  but  this  is  unusual. 

Gangrene  of  the  lung  is  not  a  common  disease.  The  diagnosis 
usually  rests  altogether  upon  the  smell  and  appearance  of  the  sputa. 
In  fetid  bronchitis  one  may  have  sputa  of  equal  foulness,  but  the 
odor  is  different.  The  finding  of  elastic  tissue  in  the  sputa  proves 
the  existence  of  something  more  than  bronchitis. 

Pulmonary  abscess,  which,  like  gangrene,  is  a  rare  affection,  is 
often  simulated  by  the  breaking  of  an  empyema  into  the  lung  and 
the  emptying  of  the  pus  through  a  bronchus.  Large  quantities  of 
pus  are  expectorated  in  such  a  condition,  and  abscess  of  the  lung  is 
suggested,  but  the  other  physical  signs  are  those  of  empyema  and 
should  be  easily  recognized  as  such.  The  Ending  oi  elastic  fibres 
is  the  crucial  j^oint  in  the    diagnosis  of  intrapulmonary  abscess, 


ABSCESS,  GANGRENE,  AND  CANCER  OF  THE  LUNG.     289 

whether  clue  to  the  tubercle  bacillus  or  to  other  organisms.  Tuber- 
culous abscess  (cavity)  is  usually  uear  the  summit  of  the  lung,  and 
other  varieties  of  abscess  are  near  the  base,  but  often  there  are 
no  physical  signs  by  which  we  can  distinctly  localize  the  process. 

Maligxaxt  Disease  of  the  Lung. 

In  its  earlier  stages  this  affection  is  often  mistaken  for  empy- 
ema or  serous  effusion  in  the  pleural  cavity,  and  indeed  the  physi- 
cal signs  may  be  in  part  due  to  an  accumulation  of  fluid  secondary 
to  the  malignant  growth  within  the  lung.  The  rapid  emaciation 
of  the  patient  and  the  presence  of  a  dark-brown  bloody  fluid  in  the 
pleural  cavity,  as  determined  by  puncture,  make  us  suspect  ma- 
lignant disease.  The  sputa  rarely  contain  fragments  of  tissue 
whose  structure  can  be  recognized  as  characteristic  of  malignant 
disease.  Secondary  deposits  in  the  supraclavicular  glands  may 
suggest  the  diagnosis. 

The  thorax  is  usually  somewhat  asymmetrical.  The  affected 
side  may  be  either  contracted  or  distended  according  to  the  nature 
of  the  malignant  growth  within ;  occasionally  it  is  not  deformed  at 
all.  When  the  growth  attacks  only  the  lung  tissue  itself,  leaving 
the  bronchi  and  mediastinum  free,  we  get  signs  like  those  of  pleu- 
ral effusion  (flatness,  absent  breathing,  voice  sounds,  and  tactile 
fremitus),  but  the  line  of  dulness  is  apt  to  be  higher  in  front  than 
behind,  which  is  rarely  the  case  in  pleural  effusion. 

If  the  disease  begins  in  the  bronchi,  we  may  have  a  noisy  dysp- 
noea from  stenosis  of  a  bronchus,  and  a  weakening  of  the  respiratory 
sounds  normally  to  be  heard  over  the  trachea  in  front  has  several 
times  been  noted.  Percussion  dulness,  if  present,  is  usually  over 
the  upper  portions  of  the  chest,  and  may  disappear  and  reappear 
or  skip  from  place  to  place  in  a  very  irregular  and  confusing  way. 

Signs  and  symptoms  of  pressure  in  the  mediastinum  due  to  sec- 
ondary involvement  of  the  peribronchial  glands  may  be  present  and 
may  simulate  aneurism,  but  with  aneurism  the  cachexia  is  usually 
less  marked. 
19 


290    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST 

Atelectasis. 

(a)  Areas  of  atelectasis  or  collapse  of  pulmonary  tissue  are 
often  present  in  connection  with  various  pathological  processes  in 
the  lung  (svich  as  tuberculosis  or  lobular  pneumonia),  but  are  usu- 
ally too  small  to  give  rise  to  any  characteristic  physical  signs; 
nevertheless 

(())  In  most  normal  individuals  a  certain  degree  of  atelectasis 
of  the  margins  of  the  lungs  may  be  demonstrated  m  the  following 
way :  The  position  of  the  margins  of  the  lungs  in  the  axillae,  in  the 
back,  or  in  the  precordial  region  are  marked  out  by  percussion  at  the 
end  of  expiration.  The  patient  is  then  directed  to  take  ten  full 
breaths,  and  the  pulmonary  outlines  at  the  end  of  expiration  are 
then  percussed  out  a  second  time.  The  pulmonary  resonance  will 
noAv  be  found  to  extend  nearly  an  inch  beyond  its  former  limits, 
owing  to  the  distention  of  previously  collapsed  air  vesicles. 

If  one  auscults  the  suspected  areas  during  the  deep  breaths 
which  are  used  to  dispel  the  atelectasis,  very  fine  rales  are  often 
to  be  heard  at  the  end  of  expiration,  disappearing  after  a  few 
breaths  in  most  cases,  but  sometimes  audible  as  long  as  we  choose 
to  listen  to  them.  These  sounds,  to  which  Abrams  has  given  the 
name  of  "atelectatic  crepitation,"  are  in  my  experience  especially 
frequent  at  the  base  of  either  axilla.  The  same  writer  has  noticed 
an  opacity  to  the  x-rays  over  such  atelectatic  areas. 

Forcible  percussion  ma}^  be  sufficient  to  distend  small  areas  of 
collapsed  lung,  or  at  any  rate  to  dispel  the  dulness  previously  pres- 
ent (see  above,  p.  76,  the  lung  reflex). 

(c)  "When  one  of  the  large  bronchi  is  compressed  (as  by  an 
aneurism)  or  occluded  by  a  foreign  body,  collapse  of  the  corre- 
sponding area  of  lung  may  be  shown  by  diminished  motion  of  the 
affected  side,  dulness  on  percussion,  and  absence  of  breathing,  voice 
sounds,  and  tactile  fremitus. 

In  ncAv-born  babies  whose  lungs  do  not  fully  expand  at  the  tune 
of  birth,  similar  physical  signs  are  present  over  the  non-expanded 
lobes.     The  right  lung  is  especially  apt  to  be  affected 

In  the  differential  diagnosis  of  extensive  pulmonary  collapse, 


ATELECTASIS,   (EDEMA,  AND  HYPOSTATIC  CONGESTION    291 

the  etiology,  the  suddenness  of  their  onset,  the  absence  of  fever  and 
of  displacement  of  neighboring  organs  enable  us  to  exclude  pneu- 
monia and  pleuritic  effusion. 

OEdema  of  the  Lungs. 

In  cardiac  or  renal  disease  one  can  often  demonstrate  that  the 
lungs  have  been  invaded  by  transuded  serum  as  a  part  of  the  gen- 
eral dropsy.  More  rarely  puhnonary  oedema  exists  without  much 
evidence  of  oedema  in  other  organs  or  tissues. 

The  only  physical  sign  characteristic  of  this  condition  is  the 
presence  of  fine  moist  rales  in  the  dependent  portions  of  the  lungs ; 
that  is,  throughout  their  posterior  surfaces  when  the  patient  has 
been  for  some  time  in  a  recumbent  position ;  or  over  the  lower  por- 
tions of  the  axillae  and  the  back  if  the  patient  has  not  taken  to 
his  bed. 

The  rales  are  always  bilateral  (unless  the  patient  has  been  lying 
for  a  long  time  on  one  side),  and  the  individual  bubbles  appear  to 
be  all  of  the  same  size,  or  nearly  so,  differing  m  this  respect  from 
those  to  be  heard  in  bronchitis.  No  squeaking  or  groaning  sounds 
are  to  be  heard.  The  respiratory  murmur  is  usually  somewhat 
diminished  in  intensity. 

Dulness  on  percussion  and  modification  of  voice  sounds  are  not 
present,  unless  hydrothorax  or  hypostatic  pneumonia  complicate 
the  oedema. 

Hypostatic  Pneumonia. 

In  long,  debilitatmg  illness,  such  as  typhoid  fever,  the  alveoli 
of  the  dependent  portions  of  the  lungs  may  become  so  engorged 
with  blood  and  alveolar  cells  as  to  be  practically  solidified.  Under 
these  conditions  examination  of  the  posterior  portions  of  the  lungs 
shows  usually : 

(a)  Slight  dulness  on  percussion  reaching  usually  from  the 
base  to  a  point  about  one-third  way  up  the  scapula.  At  the  very 
base  the  dulness  is  less  marked  and  becomes  mixed  with  a  shade  of 
tympany. 

(h)  Feeble  or  absent  tactile  fremitus. 


292     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

(c)  Diminished  or  suppressed  breathing  and  voice  sounds. 

The  right  lung  is  apt  to  be  more  extensively  affected  than 
the  left. 

Occasionally  the  breathing  is  tubular  and  the  voice  sounds  are  in- 
creased, makmg  the  physical  signs  identical  with  those  of  croupous 
pneumonia,  but  as  a  rule  the  bronchi  are  as  much  engorged  as  the 
alveoli  to  which  they  lead,  and  hence  no  breath  sounds  are  pro- 
duced. 

Rales  of  oedema  or  of  bronchitis  may  be  present  in  the  adjacent 
parts  of  the  lungs.  The  fact  that  the  dulnes?  is  less  marked  at  the 
base  of  the  limg  than  higher  up  helps  to  distinguish  the  condition 
from  hydrothorax. 

The  diagnosis  is  usually  easy,  owing  to  the  presence  of  the  un- 
derlying disease.  Fever,  pam.  and  cough  such  as  characterize 
croupous  pneumonia  are  usually  absent. 


APPENDICES. 


APPENDIX  A. 

DISEASES  OF  THE  MEDIASTINUM 

I.  Mediastixal  Tumors. 

New  growths  of  the  mediastinal  glands'  usually  manifest  their 
presence  by  the  following  symptoms  and  signs : 

(1)  Cachexia  and  substernal  pain. 

(2)  Evidence  of  pressure  against : — 

(a)  The  gullet. 

(b)  The  windpipe  or  j)rimary  bronchi. 

(c)  The  large  venous  trunks. 

(d)  Nerres  which  pass  through  the  mediastinum. 

(e)  The  subclavian  arteries. 
(/)  The  heart. 

(ff)  The  ribs,  clavicle,  or  sternum. 

(3)  Secondary  deposits  in  the  cervical  or  axillary  glands. 

(a)  By  pressure  on  the  gullet  swallowing  may  be  rendered  diffi- 
cult or  impossible  (dysphagia). 

(b )  By  pressure  on  the  windpipe  may  be  produced  displacement 
of  the  latter  to  one  side,  or  fixation  so  that  it  cannot  be  moved  in 
any  direction.  The  larynx  may  be  drawn  down  into  a  noticeably 
low  position,  and  the  laryngoscope  may  demonstrate  that  the  tra- 
cheal wall  is  bulged  inward  by  the  pressure  of  the  new  growth 
upon  it. 

Dyspnoea,  either  inspiratory  or  expiratory,  or  both,  and  often 

'  Tuberculous  glands  not  being  here  included. 


294    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

of  noisy  strident  type,  may  result  from  stenosis  of  the  trachea  or 
primary  bronchi.  Owing  to  pressure  on  one  of  the  large  bronchi, 
the  resonance  and  breath  sounds  and  fremitus  may  be  diminislied 
over  the  corresponding  lung,  in  which  tinally  abscess  or  gangrene 
may  develop,  owhig  to  the  retention  and  decomposition  of  the 
bronchial  secretions. 

(c)  If  the  pulmonary  veins  are  pressed  upon,  a  systolic  murmur 
may  be  audible  in  the  left  back,  and  congestion  of  the  lungs  may 
ensue. 

Pressure  on  the  innominate  and  subclavian  veins  produces  cya- 
nosis or  oedema  of  the  head,  neck,  shoulder,  and  arm,  while  the 
superficial  veins  of  the  chest  may  become  enlarged  and  prominent 
owing  to  an  attempt  at  collateral  circulation,  especially  if  l,he  vena 
cava  superior  is  pressed  upon.  Fluid  may  accumulate  in  one  or 
both  pleural  cavities  if  the  vena  azygos  or  thoracic  duct  is  in- 
volved. 

(d)  Aphonia  or  hoarseness  points  to  pressure  on  the  recurrent 
laryngeal  nerve,  and  on  laryngoscopic  examination  one  vocal  cord 
may  be  found  in  the  cadaveric  position.  Inequality  of  the  pui:)ils, 
due  to  pressure  on  the  sympathetic  nerves,  is  not  uncommon,  and 
severe  pain  along  the  distribution  of  the  intercostals  or  running 
down  the  arm  indicates  that  the  spinal  ganglia  or  brachial  plexus 
are  pressed  upon.  Much  rarer  are  symptoms  of  pressure  on  the 
vagus  (slowing  or  quickening  of  the  heart)  and  on  the  phrenic 
nerve  (hiccup,  unilateral  spasm,  or  paralysis  of  the  diaphragm). 

(e)  Weakening  or  delay  in  one  radial  pulse  may  be  due  to  press- 
ure on  the  subclavian  artery. 

(/)  Occasionally  the  heart  itself  may  be  pushed  out  of  place, 
((/)  Pressure  of  the  new  growth  against  the  bones  of  the  chest 
may  give  rise  to  an  area  of  percussion  dulness  over  or  near  the 
manubrium,  which,  however,  is  not  likely  to  show  itself  until  late 
in  the  course  of  the  disease  when  the  new  growth  has  reached  a 
considerable  size.  In  many  cases  there  is  tympanitic  resonance  in- 
stead of  dulness  over  the  affected  area.  The  ribs  or  sternum  may 
be  pushed  forward,  but  this  is  not  usually  the  case.  Occasionally 
the  new  growth,  if  very  vascular,  may  pulsate  like  an  aneurism  or 


DISEASES  OF  THE  MEDIASTINUM.  295 

transmit  the  pulsations  of  the  heart  to  the  chest  wall,  and  a  systo- 
lic niui-niur  may  be  heard  over  the  pulsating  area,  so  that  the  resem- 
blance to  aneurism  is  increased. 

Differential  Diagnosis. 

Mediastinal  tumors  may  be  mistaken  for 

(1)  Aneurism  of  the  aortic  arch. 

(2)  Syphilitic  stenosis  of  a  bronchus. 

(3)  Phthisis. 

Aneurism  may  be  confounded  with  mediastinal  new  growths 
even  by  the  most  competent  observers.  Tactile  thrill,  diastolic 
shock,  and  tracheal  tugging,  if  present,  should  suggest  aneurism. 
If  these  signs  are  absent,  aneurism  may  still  be  present  but  cannot 
be  surely  diagnosed.  The  degree  of  anaemia  and  emaciation  is  usu- 
ally greater  in  malignant  disease  than  in  aneurism,  but  this  is  not 
always  the  case.  The  presence  of  secondary  nodules  in  the  neck  or 
armpit  speaks  strongly  in  favor  of  new  growth. 

Stenosis  of  a  bronchus,  due  to  syphilis  and  giving  rise  to  dysp- 
noea, cough,  stridor,  pulmonary,  atelectasis,  may  be  very  difficult  to 
distinguish  from  mediastinal  growth,  but  the  degree  of  anaemia  and 
emaciation  is  usually  less  in  syphilis,  and  the  beneficial  results  of 
antisyphilitic  treatment  may  render  the  diagnosis  possible,  espe- 
cially if  there  is  evidence  of  syphilis  elsewhere  in  the  body  or  in 
the  history  of  the  case. 

Phthisis  may  be  suggested  by  the  weakness,  emaciation,  and 
persistent  cough  produced  by  mediastinal  growths,  but  should  be 
easily  excluded  by  the  examination  of  the  lungs  and  sputa. 

II.  Mkdiastinitis. 

The  acute  suppurative  forms  of  this  rare  disease  do  not  give  rise 
to  any  characteristic  physical  signs  in  the  chest. 

The  evidences  of  chronic  fibrous  mediastinitis  have  been  already 
sufficiently  considered  in  connection  with  adhesive  pericarditis. 


296    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST 

III.    Tuberculosis  of  the  ]\rEDiASTixAL  Glaxds. 

Probably  every  case  of  pulmonary  tuberculosis  is  preceded  or 
accompanied  by  tuberculosis  of  the  bronchial  lymph  glands,  and  in 
numberless  cases  the  tuberculous  process  never  gets  beyond  these 
glands  but  is  choked  olf  there.  In  post-mortem  examinations  of 
children,  no  matter  what  the  cause  of  death,  it  is  exceptional  not 
to  find  the  bronchial  glands  tuberculous. 

Nevertheless  the  disease  can  but  rarely  be  recognized  during 
life.  We  may  suspect  it  if,  in  a  child  showing  tuberculous  cervical 
glands  or  phthisis,  we  find  evidence  of  pressure  upon  the  right 
bronchus,  increased  tactile  fremitus  above  the  manubrium,  lateral 
displacement  of  the  trachea,  or  weakening  of  the  pulse  during  in- 
spiration. If  a  bronchus  is  compressed,  the  resonance,  tactile 
fremitus,  and  breath  sounds  are  diminished  over  the  correspond- 
ing lung.  Wiederhofer  lays  stress  upon  an  increase  in  the  inten- 
sity of  the  expiratory  murmur  over  the  situation  of  the  left  primary 
bronchus. 


APPENDIX   B. 
ACUTE  ENDOCARDITIS. 

Whether  the  disease  be  of  the  benign  or  of  the  malignant  (sep- 
tic) type,  the  results  of  physical  examination  of  the  heart  are  usu- 
ally very  equivocal.  We  may  guess  that  endocarditis  is  present 
owing  to  the  presence  of  a  cause  (rheumatism),  of  a  fever  not  oth- 
erwise explained,  of  a  rapid  irregular  pvilse  of  low  tension,  but  the 
physical  signs  over  the  heart  will  not  usually  assist  our  guess  ma- 
terially. 

Murmurs  are  often  present  but  have  usually  the  characteristics 
of  "  functional "  murmurs  (systolic,  limited,  soft,  without  accentu- 
ation of  the  pulmonic  second  sound  or  cardiac  enlargement).  If 
we  can  observe  the  advent  of  a  diastolic  murmur  in  such  a  case,  we 
may  fairly  attribute  it  to  a  fresh  endocarditis  of  the  aortic  (very 
rarely  of  the  pulmonic)  valve,  but  if  we  have  not  had  the  oppor- 


PHYSICAL  EXAMINATION  OF  THE  CHEST  IN  INFANTS.     297 

tunity  to  examine  the  heart  previous  to  the  onset  of  the  preseyit 
attack  it  is  impossible  to  exclude  a  long-standing  valvular  lesion  as 
the  cause  of  the  murmur. 

If  murmurs  come  and  go  from  day  to  day,  or  suddenly  increase 
in  intensity,  we  may  suspect  an  acute  endocarditis,  especially  if  a 
musical  murmur  is  present  or  if  there  be  evidence  of  embolism. 

Inspection,  palpation,  and  percussion  usually  yield  no  signs  of 
importance.  There  is  no  enlargement  of  the  heart,  no  accentuation 
of  the  second  sounds,  and  no  evidence  of  stasis. 


APPEK^DIX  C. 
PHYSICAL  EXAMINATION  OF  THE  CHEST  IN  INFANTS. 

(1)  Tactile  fremitus  and  voice  sounds  can  be  investigated  only 
in  case  the  child  cries  or  crows.  The  cry-souncl  is  intensified  over 
solidified  areas  and  may  or  may  not  be  lost  over  fluid  accumula- 
tions. 

(2)  Percussion  must  be  very  delicately  performed  if  we  are  to 
avoid  setting  the  whole  chest  in  vibration  with  every  stroke.  It  is 
best  to  strike  wholly  with  the  finger,  keei^ing  the  hand  (as  well  as 
the  wrist  and  arm)  unmoved. 

(3)  In  listening  to  an  infant's  lungs  patience  and  concentration 
ai'e  essential.  The  child  is  apt  to  stoj)  breathing  when  the  exami- 
nation begins,  and  we  have  to  wait  patiently  to  catch  the  long-de- 
layed inspiration  "  on  the  wing, "  as  it  were,  before  the  long  expi- 
ratory wail  begins.  Luckily  the  inspiration,  when  it  does  come,  is 
unusually  intense  owin^  to  the  thinness  of  the  chest  in  infancy. 

(4)  Long  flexible  rubber  tubes  connecting  the  chest-piece  of  the 
stethoscope  with  the  ear-pieces  are  very  convenient  when  examin- 
ing a  wriggling  child  (see  Fig.  48,  p.  79),  as  they  make  it  possible 
to  hold  the  chest-piece  in  position  despite  the  constant  movements 
of  the  struggling  sufferer. 

(5)  It  is  advisable  to  examine  first  the  back  while  the  child  is 
held  in  the  mother's  arms  with  its  back  to  the  physician. 


298     PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

(6)  Children  almost  always  eiy  if  made  to  lie  down  flat.  If 
we  wish  to  bring  out  the  cry  sound  in  order  to  test  the  vocal  and 
tactile  fremitus,  this  is  a  simple  and  humane  method  of  producing 
it.  If,  on  the  other  hand,  peace  is  what  we  most  desire,  it  is  best 
to  avoid  putting  the  child  in  a  recumbent  position. 

(7)  There  is  no  type  of  breathing  peculiar  to  children  or  in- 
fants. Puerile  breathing  is  simply  vesicular  breathing  heard  very 
distinctly  on  account  of  the  thinness  of  the  chest.  If,  in  a  healthy 
child,  the  expiratory  murmur  is  prolonged  and  high-pitched,  this  is 
probably  because  the  child  blows  out  the  breath  forcibly  in  the 
effort  to  breathe  deeply  as  it  is  told  to  do.  A  young  infant  never 
does  this,  and  its  breathing  is  like  that  of  adults  except  that  it  is 
more  rapid,  more  irregular,  and  better  heard. 


APPENDIX  D. 

RADIOSCOPY  OF  THE  CHEST. 

Radioscopy  gives  assistance  in  the  diagnosis  of  diseases  of  the 
chest  in  two  ways : 

1.  Through  the  use  of  the  fluoroscopic  screen. 

2.  Through  the  use  of  radiogi-ajjhs. 

Those  who  are  accustomed  to  the  use  of  the  fluoroscope  gain 
far  more  information  from  it  than  from  radiographs,  but  the  record 
of  the  photographic  plate  is  objective,  permanent,  and  demon- 
strable, wliile  the  hnpressions  gained  from  the  fluoroscope  are  more 
apt  to  be  modified  by  the  personal  equation. 

For  the  present,  therefore,  we  need  both  methods. 

I  shall  not  attempt  to  discuss  the  advantages  of  the  various 
forms  of  apparatus  used  for  producing  Roentgen  rays  in  a  Crookes  • 
tube ;  the  subject  would  carry  me  beyond  my  depth  as  well  as  be- 
yond the  limits  of  this  book ;  but  whatever  form  of  instrument  is 
used,  the  vacuum  in  the  tube  should  be  less  perfect  when  we  desire 
to  use  it  for  the  chest  than  when  searching  for  foreign  bodies  or 
studying  fractures.     We  need  a  "  low  "  or  "  soft "  tube  which  gives 


RADIOSCOPY  OF  THE  CHEST.  299 

rays  of  a  relatively  slight  degree  of  penetration.  With  high  i>ene- 
tration  rays  the  outlines  of  the  solid  organs  are  less  distinct  because 
the  rays  traverse  the  heart  and  liver  almost  as  easily  as  they  do  the 
lungs.  If  the  penetrating  power  is  less,  the  rays  are  arrested  by 
the  solid  organs,  but  not  by  the  lungs,  and  hence  the  outlines  of  the 
former  become  visible. 

/.  The  Use  of  the  Fluoroscope. 

1.  It  is  advisable  to  remain  hi  a  dark  room  or  to  wear  smoked 
glasses  for  a  short  thne  before  attempting  to  use  the  fluoroscope. 
This  applies  especially  to  beginners.  Skilled  observers  do  not  need 
such  preparation  of  the  retina,  but  many  novices  who  complain  at  lirst 
that  they  can  "  see  absolutely  nothing  "  when  they  apply  the  fluoro- 
scope to  the  chest,  find  their  vision  suddenly  and  permanently  im- 
proved after  fifteen  minutes  in  a  dark  room.  Practice  increases  our 
powers  with  the  fluoroscope  as  much  as  it  does  with  the  micro- 
scope, and  it  is  unreasonable  to  expect  to  see  from  the  first  all  that 
an  expert  sees. 

2.  The  patient  should  be  placed  at  least  three  feet  from  the 
tube,  else  there  is  likely  to  be  distortion  and  magnification  of  the 
shadows  corresponding  to  the  organs  examined.  The  tube  should 
be  placed  at  such  a  height  as  to  be  opposite  the  most  important 
object  to  be  examined,  and  always  in  the  median  line. 

3.  Patients  may  be  examined  either  in  the  upright  position — 
the  tube  about  three  feet  from  the  patient's  back — the  fluoroscope 
resting  against  the  chest — or  in  the  recumbent  position,  supported 
on  a  canvas  cot  with  the  tube  underneath.  I  prefer  the  upright 
position.  The  patient's  arms  should  always  be  extended  forward 
so  as  to  get  the  scapulae  out  of  the  way. 

4.  To  concentrate  the  light  upon  a  spot  of  special  interest,  we 
may  use  a  metal  plate  with  a  rectangular  opening  about  two  by 
three  inches  near  one  end.  When  this  plate  is  held  between  the 
tube  and  the  patient,  so  that  the  opening  is  opposite  the  spot  to 
be  examined,  the  rays  pass  through  the  opening,  but  are  intercepted 
by  the  metal  around  it.  The  hand  which  holds  this  plate  should 
be  protected  from  the  action  of  the  rays. 


300    PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST. 

5.  To  mark  on  the  chest  the  outlines  of  the  shadows  seen  with 
the  fluoroscope,  a  pencil  enclosed  in  a  tube  of  brass  is  useful ;  the 
brass  jacket  makes  the  pencil  visible  and  enables  us  to  adjust  its 
pomt  to  the  ou times  on  the  chest.  An  ordinary  pencil  is  pene- 
trated by  the  rays  completely,  and  it  is  hard  to  draw  with  a  pencil 
which  we  cannot  see. 

II.  Tlte  Normal  Fluoroscopic  Picture  (see  Fig,  138). 

The  lungs  appear  as  the  lightest  part  of  the  field  owing  to  the 
large  amount  of  air  they  contain ;  at  the  end  of  full  inspiration, 
they  become  still  lighter.  Against  the  light  lung  areas,  the  out- 
lines of  the  ribs  and  of  the  vertebral  column  (with  the  sterniim  super- 
imposed) are  clearly  "s-isible.  Less  clear,  but  usually  quite  distin- 
guishable, are  the  outlines  of  the  heart  and  the  upper  border  of  the 
liver.  A  slight  shadow  (see  Fig.  139)  is  often  noticed  just  to  the 
right  and  to  the  left  of  the  heart  in  a  position  corresponding  to  the 
larger  bronchi.  The  spleen  is  not  usually  to  be  made  out  clearly, 
but  the  upper  surface  of  the  diaphragm  above  it  is  generally  visible. 
The  contractions  of  the  heart  and  the  movements  of  the  diaphragm 
are  usually  clear,  and  any  restriction  of  the  respiratory  excursion 
on  one  side  can  be  noted,  though  the  fluoroscope  has  no  advantages 
over  the  inspection  of  Litten's  diaphragm  shadow  (see  p.  23)  for 
this  purpose. 

Abrams  has  noted  that  if  the  skin  of  the  precordia  is  irritated 
by  cold  or  pain,  a  reduction  in  the  size  of  the  heart  occurs  ("heart 
reflex  ")  for  a  few  seconds. 

In  children  all  these  phenomena  are  especially  clear,  owing  to 
the  thiuQess  of  their  chest  walls  and  we  note  at  once  how  much 
more  horizontal  the  child's  heart  is  than  the  adult's  (see  Fig.  138). 

///.  The  Fluoroscope  in  Disease. 

I  shall  mention  first  those  diseases  in  which  the  fluoroscope  fur- 
nishes us  the  most  valuable  information. 

1.  Aneurism. — Small  aneurisms  of  the  transverse  or  descending 
aorta  may  sometimes  be  recognized  by  the  ar-rays  when  no  other 


RADIOSCOPY  OF  THE  CHEST. 


301 


1 


if 


Chest  of  Healthy  Coy  aged 
niue  years. 


Incipient  Phthisis  at  Right         Chest  of  Healthy  Adult. 
Apex. 


Advanced  Phthisis  (cavity?).  Advanced  Phthisis.  Bilateral  Phthisis  at  Apices. 


Advanced  Phthisis. 


Advanced  Phthisis.  Pulmonary  Emphysema. 


rii 


Aortic  Aneurism.  AncuiiMu  nf  Left  Auricle.       Fibroid  Phthisis  of  Right  Lung. 

Heart  drawn  to  the  right. 

Fig.  138.— Twelve  Radiographs  of  the  Chest,  as  Seen  from  Behind  (after  Walsbam). 


302     PHYSICAL  DIAGNOSIS   OF  DISEASES  OF  THE  CHEST. 

method  of  physical  examination  yields  satisfactory  evidence.  An 
abnormal  shadow  appears  at  one  side  of  the  sternum  (see  Fig.  140) 
and  may  sometimes  be  seen  to  pulsate.  In  other  cases  the  fluoro- 
scopic evidence  is  not  the  only  evidence,  but  tends  to  confirm  or 


Fig.  139.— Radiograph  of  a  Case  of  Transposition  of  tlie  Viscera.     (After  Gibson.) 


dispel  suspicions  aroused  by  the  ordinary  methods  of  examination. 

Aneurism  of  the  heart  itself  is  recognizable,  according  to  F.  H. 
Williams,  by  the  fluoroscoi)ic  examination.  Ko  other  method  of 
examination  gives  us  any  evidence  of  such  a  lesion. 

2.  Determ/buition  of  the  Cardiac  Outlines  in  Patients  with  Em- 
physema and  Fat  Chest  Walls. — Emphysema  spoils  cardiac  percus- 


RADIOSCOPY  OF  THE  CHEST.  303 

siou  and  interferes  with  inspection  and  palpation.  But  in  fluoro- 
scopic work  emphysema  is  a  boon  and  a  blessing,  for  it  renders  the 
cardiac  outlines  more  distinct  than  usual.  Hence,  for  determining 
the  size  and  position  of  the  heart  in  such  cases,  the  a-rays  give 
genuine  assistance,  as  they  also  do  when  mappmg  out  the  heart  in 
women  with  large  breasts  and  fat  chest  walls, 
♦    3.    Central  Pnemnonia. — Williams  and  others  have  succeeded 


Aneurlsmalsac. 


Heart. 


Fig.  140.— Front  View  of  Thoracic  Aneurism.    The  heart  displaced  downward. 

in  identifying  foci  of  solidification  beneath  the  surface  of  the  lungs 
when  no  other  physical  signs  could  be  obtained.  It  must  be  re- 
membered, however,  that  congestion  of  the  lung,  oedema,  atelec- 
tasis, and  pleural  thickening  produce  shadows  similar  to  those  of 
solidified  lung. 

4.   Tuberculosis.— It  is  still  a  matter  of  doubt  whether  tubercu- 
lous foci  can  be  recognized  by  the  fluoroscope  before  the  disease  has 


304     PHYSICAL  DIAGNOSIS   OF  DISEASES   OF  THE  CHEST. 

progressed  sufficiently  to  prodvice  localized  rales,  dhuinished  breath 
sounds,  or  restriction  of  Litten"  s  i:)hrenic  phenomenon. 

Slight  opacities  have  been  noted  in  cases  Avhich  later  turned  oiit 
to  be  tuberculosis,  and  which  had  not  previously  been  diagnosed, 
but  the  shadows  perceived  by  the  fluoroscope  are  capable  of  many 
interpretations  and  correspond  (as  above  said)  to  various  pathologi- 
cal conditions.     Old  quiescent  foci  may  appear  like  advancing  le- 


Aneurismal  sac. 


Heart. 


Fig.  141.— Aneurismal  Sac  Radiographed  from  Behind. 

sions  and  thus  lead  to  serious  errors.  We  do  not  want  to  hurry  a 
patient  off  to  Colorado  or  Davos  on  account  of  the  shadow  thrown 
by  a  long-healed  lesion.  Further,  in  some  cases  of  rheumatism, 
anaemia,  debility,  and  convalescent  typhoid,  appearances  very  simi- 
lar to  those  of  tuberculosis  may  be  found  (Williams).  Hence  the 
intrepretation  of  slight  lung  shadows  in  cases  of  suspected  incipient 
phthisis  is  by  no  means  easy. 


RADIOSCOPY  OF  THE  CHEST.  305 

Advanced  phthisis  renders  the  hmgs  relatively  opaque  to  the 
Eoentgen  rays  except  where  extensive  excavation  has  occurred; 
here  we  see  a  light  area  in  a  dark  background  (see  Fig.  1,']8). 

No  satisfactory  radiographs  of  cases  of  iiicijnent  phthisis  have 
so  far  been  published,  so  far  as  I  am  aware. 

6.  Pleuritic  Effusions. — The  displacement  of  the  heart  is  some- 
times better  shown  by  the  cc-rays  than  by  ordinary  methods  of  ex- 
amination, since  the  compensatory  hypertrophy  of  the  sound  lung, 
which  interferes  with  percussion  and  palpation  of  the  heart,  renders 
radioscopy  easier. 

The  fluid  exudate  intercepts  the  rays  perceptibly,  and  when  the 
movements  of  the  diaphragm  are  not  abolished  on  the  affected  side, 
the  line  corresj^onding  to  the  surface  of  the  fluid  can  be  seen  to 
move  up  and  down  with  respiration. 

Small  fluid  accumulations  flatten  the  normal  curve  of  the  upper 
surface  of  the  diaphragm  by  filling  iip  the  chink  between  the  inner 
surface  of  the  chest  in  the  axilla  and  the  line  of  the  diaphragm  at 
that  point. 

6.  Emjihysema. — The  lungs  become  unusually  transparent  and 
owing  to  the  low  poeition  of  the  diaphragm  the  heart  descends  and 
assumes  a  very  vertical  position  ("ptosis  of  the  heart");  these 
points  are  very  clearly  seen  with  the  fluoroscope. 

Radiographs. 

But  little  use  has  thus  far  been  made  of  radiographs  in  study- 
ing diseases  of  the  chest.  The  movements  of  the  heart,  of  the 
chest  walls,  and  of  the  diaphragm  render  all  the  outlines  .indistinct. 
For  aneurisms,  especially  those  containing  a  thick  layer  of  clot,  and 
for  intrathoracic  tumors,  radiographs  may  be  very  useful,  and 
bronchial  lymph  glands  are  sometimes  rendered  visible. 
20 


306     PHYSICAL  DIAGXOSIS   OF  DISEASES   OF  THE  CHEST. 

APPENDIX   E. 
THE  SPHYGMOGRAPH. 

This  mstniment  consists  of  a  system  of  levers  by  means  of  which 
the  pulsations  of  the  radial  ai-tery  are  transferred  to  a  needle  whose 
oscillations  can  be  graphically  recorded  upon  a  piece  of  smoked  pa- 
per. It  is  a  very  fascinatiag  little  toy,  but  in  its  present  form  is 
almost  devoid  of  practical  usefulness  owing  to  the  impossibility  of 
eliminating  the  personal  equation  when  using  it.  The  size  and,  to 
a  certain  extent,  the  shape  of  the  wave  traced  upon  the  smoked 
paper  can  be  influenced  at  will  by  the  amount  of  pressure  with 
which  the  instrument  is  applied  to  the  wrist.  If  an  insti-ument  is 
applied  with  a  pressure  of  three  ounces  to  the  wrist  of  A,  and  then 
Avith  the  same  pressure  to  the  wrist  of  B,  the  force  exerted  upon 
the  artery  may  be  quite  different  in  the  two  cases  owing  to  the  dif- 
ferent shape  of  the  wrist  in  the  two  individuals. 

Almost  any  type  of  tracing  can  be  obtained  from  a  normal  pulse 
by  varying  the  pressure. 

This  objection  is  fatal  to  the  use  of  the  sphygmograph  as  an  in- 
strument of  precision,  and  although  it  is  capable  of  recording  tiny 
secondary  waves  unpalpable  by  the  fingers,  it  has  yet  to  be  shown 
that  it  reveals  anything  of  practical  diagnostic  value  which  is  not 
appreciated  by  skilled  fingers.  For  these  reasons  I  have  given  no 
accoimt  of  the  instrument  in  the  body  of  this  work. 


INDEX. 


Abrams,  76,  105,  202 

Abscess,  pulmonary,  290 

Adenitis,  41 

Amphoric  breathing,  103 

Anatomy,  2 

Aneurism,  220-229.  293 

Aortic  aneurism,  33.  220-229 

disease,  170-187 

regurgitation,  170 

roughening.  1S4 

second  sound,  121 

stenosis,  181 
Apex,  cardiac,  displacement  of,  29 

position  of,  26 

retraction,  31 
Arrhythmia,  161,  204 
Arterial  movements,  36 

murmurs,  140 

sounds,  124 

wall,  condition  of,  55 
Asthma,  261,  263 
Atelectasis,  104,  292 
Auscultation,  77-141 

mediate  and  immediate,  78 

of  the  heart,  113-141 

of  the  lungs,  91-112 

Barrel  chest.  9 

Bradycardia,  51.  203 

Breathing   (see  Eespiration),   16,   21, 

23.  92 
Broadbent.  161,  217 


Bronchial  (see  Tubular) 

breathing,  95,  102,  239.  280 
Bronchiectasis,  264 
Bronchitis,  233,  245 

Cancer  of  lung,  291 
Capillary  pulse,  38,  172 
Cardiac  (see  Heart) 
impulse,  23,  42 

displacement  of,  29,  281 

character  of,  148 
Cirrhosis  of  tlie  lung.  265 
Compensation,      establishment     and' 

failure  of,  144 
Congenital  heart  disease,  206 
Cough,  effect  of,  107,  245 
Curvature,  spinal,  14 
Cyanosis,  39 

Deformities,  14 
Diaphragm,  movements  of,  23 
Diastolic  murmur,  137,  181,  192 

shock,  222 

soimd,  164,  225 
Dilatation,  cardiac,  146,  199 
Ductus  arteriosus,  persistence  of,  207 
Dyspnoea,  18 

Egophony,  111 
Emphysema,  258 

complementary,  262 

interstitial,  262 

large-lunged,  258 


308 


INDEX. 


Emphysema,  senile,  258 

with  bronchitis,  261 
Empyema,  283,  284 
Endocai'ditis,  acute,  296 

chronic,  151 
Epigc^tvic  pulsation,  32 
Expansion,  16 

diminished,  17 

increased,  18 

Fatty  nEGEXERAXiON,  201 

overgi'owth.  201 
Flattening  of  the  chest,  14 
Foramen  ovale,  patency  of,  207 
Fremitus,  tactile,  44 

vocal,  109 
Friction,  pleural,  107,  271 

pericardial,  209 

Gangrene  of  lcngs,  290 
Glands,  41 

H.EMIC    MURMURS,    136 

Heart  (see  also  Cardiac),  141 
aneurism  of,  301 
dilatation  of,  146 
diseases  of,  141-205 
hypertrophy  of,  146 
murmvu"S,  126 

sounds,  accentuation  of,  120 
doubling  of,  118 
metallic,  124 
muffled,  124 
rhythm  of,  123 
shortening  of,  117 
Hj-cb'opericardium,  219 
Hydrothorax,  266 

Hypertrophy,  cardiac,  signs  of,  146 
Hypostatic  congestion  of  lung,  293 

IxFANTs,  examination  of,  297 
Jauxi>ice,  40 


LiTTEN,  23 

Lung  reflex,  76 
Lungs,  abscess  of,  290 

cancer  of,  291 

diseases  of,  23;i-293 

emphysema  of,  258 

fistula-sound,  112 

gangrene  of.  290 

oedema  of,  293 

Mediastinal  tuberculosis,  296 

tumors,  293 
Mediastinitis,  216,  295 
Mediastinum,  diseases  of.  293 
Metallic  heart  sounds,  124 

tinkle,  112 
Mitral  valve,  diseases  of,  151-170 

iiLsufficiency  of,  151 

stenosis  of,  161 
Murmurs,  arterial,  140 

cardiac,  126-140 

cardio-respiratory,  138 

functional  or  hsemic,  136 

venous,  139 
Muscle-sounds,  84 
Myocarditis,  acute,  199 

chronic,  201 

Neuroses,  cardiac,  202 
CEi>ema,  235,  293 

Pallor,  40 

Palpation,  42 

Palpitation,  205 

Paralytic  chest,  8 

Parietal  disease  (see  Myocarditis),  198 

Percussion,  58 

auscultatory,  65 

immediate,  58 

mediate,  58 

palpatory,  67 

resonance,  67 


y, 


INDEX. 


309 


Pei'cussion  resonance,  amphoric,  75 
cracked-pot,  74 
diminished,  69 
tympanitic,  70 
vesicular,  68 

technique  of,  58 
Pericardium,  diseases  of,  209,  219 
Pericarditis,  209 

adhesive,  32,  216 

plastic,  209 

with  effusion,  212 
Phthisis,  252 
Pleural  thickening,  283 
Pleurisy,  271-284 

encapsulated,  283 

plastic,  271 

pulsating,  284 

with  effusion,  273 
Pneumonia,  croupous,  237 

inhalation,  244 
Pneumohydrothorax,  208 
Pneumothorax,  111,  266 
Pulmonary  abscess,  290 

atelectasis,  104,  292 

emphysema,  258 

gangrene,  290 

oedema,  293 

regurgitation,  192 

stenosis,  193 

tuberculosis,  245 

tympanites,  262 
Pulmonic  second  sound,  120 
Pulsation,  abnormal,  48 
Pulse,  49 

capillary,  173 

compressibility  of,  52 

Corrigan's,  172 

dicrotic,  52 

rate,  51 

rhythm,  51 

tension,  53 

wave,  size  and  shape  of,  52 


Kachitis,  effects  on  the  thorax,  7 
Radioscopy,  227,  298 
Rales,  103 

bilateral,  234 

crepitant,  105 

dry,  104 

moist,  104 

musical,  106 

palpable,  47 

subcrepitant,  105 

unilateral,  245 
Resistance,  sense  of,  76 
Resonance  (see  Percussion),  67 
Respiration,  amphoric,  98 

asthmatic,  21,  97,  263 

bronchial  or  tubular,  95 

broncho-vesicular,  96 

Cheyne-Stokes,  22 

cogwheel,  98 

diminished,  100,  279 

emphysematous,  97 

exaggerated,  99,  206,  279 

metamorphosing,  98 

normal,  68 

restrained,  22 

shallow,  23 

stridulous,  23 

types  of,  92 

vesicular,  93     ^ 
Rhythm,  cardiac,  123,  165 

modifications  of,  123,  166 

respiratory,  21 

Sphtgmograph,  285 
Stethoscope,  choice  of,  78 

use  of,  83 
Succussion,  111 
Syphilis  of  the  lung,  264 

Tachycardia,  202 

Tactile     fremitus     (see     Fremitus)  5 
44 


310 


INDEX. 


Tension  of  the  pulse,  53 
Thrills,  43 

in  aneurism,  222 

in  aortic  stenosis,  184 

in  congenital  heart  disease,  206, 
208 

in  mitral  stenosis,  164 
Tracheal  tug,  223 
Tracheitis,  233 
Tricuspid  regurgitation,  187 

stenosis,  191 
Tuberculosis,  advanced,  249 

incipient,  245 

pulmonary,  244 


Tumors,  15,  48,  221,  291,  293 

Valve  areas,  113 

lesions,  151-197 
Valvular  disease,  141,  151-197 

heart  sounds,  117,  199,  202 
Venous  murmur,  139 

pulsations,  35,  188 

sound, 125 
Ventricle,  left,  hypertrophy  of,  147 

right,  hypertrophy  of,  148 
Ventricular  septum,  defects  in,  207 
Voice  sounds,  spoken,  110 

whispered,  109,  238 


Date  Due 

PMiNTEo  IN  u.s.«.            CAT.   NO.   24    161               Sw 

A  000  502  591  1 


WF975 
Cll6p 

1901 
Cabot,  Richard  C 

Phyeical  diagnosis  of  diseases  of  the 
chest . 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


